Methods of treating female infertility

ABSTRACT

Further according to the present disclosure, there are methods for promoting egg maturation in assisted reproductive technologies, such as in in vitro fertilization (IVF) or in an embryo transfer (ET) process. There are also methods for decreasing the rate of ovarian hyperstimulation syndrome (OHSS), providing comparable or improved pregnancy rates, decreasing the time to pregnancy, and inhibiting premature ovulation. The methods include the step of administering a therapeutically effective amount of an active pharmaceutical ingredient of 2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl) hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or a pharmaceutically acceptable salt thereof.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation application of InternationalApplication No. PCT/EP2017/074800, filed Sep. 29, 2017, which claims thebenefit of U.S. Provisional Application No. 62/402,018, filed Sep. 30,2016; and U.S. Provisional Application No. 62/402,150, filed Sep. 30,2016, the entireties of which are incorporated herein by reference.

REFERENCE TO A SEQUENCE LISTING

The Sequence Listing associated with this application is provided intext format in lieu of a paper copy, and is hereby incorporated byreference into the specification. The name of the text file containingthe Sequence Listing is MYOV_017_01US_SeqList_ST25.txt. The text file isabout 1 Kilo Bytes, was created on Mar. 29, 2019, and is being submittedelectronically via EFS-Web.

FIELD

The present disclosure is in the field of assistive reproductivetechnology (ART), and more specifically to methods and uses forperforming ART in women who are at risk for OHSS and to methods and usesfor promoting egg maturation, luteal phase support, and inhibitingpremature ovulation.

BACKGROUND

Approximately 1.5 million assisted reproduction cycles are performedeach year worldwide. Further, approximately 25% of women suffering frominfertility have problems achieving ovulation, including the inabilityto produce fully-matured eggs (also referred to as oocytes) or thefailure to ovulate. Fertility specialists assist reproduction by using agroup of medications to temporarily correct ovulatory problems and toincrease a woman's chance for pregnancy. Many assisted reproductioncycles include one or more of the following steps as part of theultimate goal of pregnancy: (1) maturation of the ovarian follicles,which control the release of eggs in the ovaries; (2) prevention ofpremature ovulation; (3) triggering egg maturation at the appropriatetime; (4) egg retrieval and fertilization; and (5) transplantation offertilized egg followed by biochemical tests for pregnancy. However,other important ART regimens include oocyte banking or donation;menstrual cycle regulation, in which ovulation is allowed to occur aftertriggering (3) and then is followed by intrauterine insemination (IUI)or intercourse at a specified time. Also, for women with primary ovarianfailure (e.g., women who are unable to bring an oocyte to maturity orovulate even with ART), or as part of a surrogate procedure, embryotransfer (ET) with luteal phase support may be utilized, where theluteal phase support agent may be administered before, at the same timeas, or after ET, or administered at one or more of the foregoing times.

Traditionally, ART protocols have used agents like follicle stimulatinghormone (FSH) and human menopausal gonadotropin (hMG) during the initialstimulation phase, either preceded by administration of agonadotropin-releasing hormone (GnRH) agonist (GnRH receptor agonist) orby the addition of a GnRH antagonist (GnRH receptor antagonist) toprevent (suppress) ovulation and prevent the release of prematureoocytes due to a luteinizing hormone (LH) surge. Ovulation is suppressedso that eggs may mature and later be retrieved directly from the ovaries(instead of the fallopian tubes) and also to prevent high-order multiplegestation that may result from exposure of eggs to sperm in thefallopian tube if intercourse has occurred. Together, this stimulationprocess with FSH and a GnRH antagonist or agonist is called controlledovarian stimulation (COS). Once the follicles have progressed to apre-defined state, in which a number of oocytes are ready for finalmaturation, an oocyte maturation agent, or a so-called “trigger” agent(e.g., human chorionic gonadotropin hormone (hCG or HCG), a GnRHagonist, or both), is used to (1) promote final maturation and releaseof eggs from the ovary in preparation for intercourse or IUI, or (2) forfinal maturation and oocyte retrieval followed by ET to the uterus, forART regimens that include an implantation step (e.g., in vitrofertilization (IVF)). Induction of final maturation of oocytes is aprocedure that is usually performed as part of COS to render the oocytesfully developed, thereby resulting in a good yield of oocytes forretrieval and to optimal pregnancy chances. Thus, the trigger isessentially a replacement for the LH surge whose effects include finalmaturation of oocytes prior to ovulation in natural menstrual cycles. Incycles of IVF, final oocyte maturation triggering with a GnRH agonistinstead of hCG decreases the risk of ovarian hyperstimulation syndrome(OHSS), but also decreases live-birth rates. In ART cycles followed byoocyte donation, use of GnRH agonists instead of hCG decreases the riskof OHSS with no evidence of a difference in live-birth rate. GnRHagonist and hCG triggered cycles of IVF afford similar oocyte yields andembryo quality.

After the trigger agent is administered, other agents (e.g., hCG andestradiol and progestins) are used to support the uterus (endometrium),so-called luteal phase support, in preparation for implantation. Lutealphase support is needed because after COS with gonadotropins, there is adefect due to supraphysiological steroid hormone concentrationsinhibiting LH secretion via negative feedback at the level of thehypothalamic-pituitary-gonadal-axis. Due to the low LH levels, withoutluteal phase support, progesterone levels will drop, leading to a lowerchance of successful implantation and therefore pregnancy.

Human chorionic gonadotropin (hCG) is used as a trigger due to itsstructural similarity to LH and ability to activate LH receptors and actas a trigger agent that results in significant quantities of matureoocytes. Due to the long half-life of hCG (24-36 hours) and ability toactivate the LH receptors for seven to ten days, and sometimes even upto 16 days, hCG also provides luteal phase support, by increasingprogesterone. Thus, hCG can be used in either the trigger (oocytematuration) setting and/or for luteal phase support. Further,hCG-containing therapies as trigger agents are known to result in theproduction of significant quantities of mature oocytes. However, use ofhCG in either setting is associated with the highest risk of OHSS. Thisraises safety concerns for women at high-risk of OHSS and possibly leadsto a greater need to use segmentation freeze protocols (i.e., thecryopreservation of embryos followed by a frozen-thawed embryo transferin a subsequent menstrual cycle) that may mitigate OHSS, but will delayET and time to pregnancy. As discussed in more detail below, in OHSS,the ovaries may become enlarged, fluid may accumulate in the peritonealcavity (ascites) and the patient may experience abdominal distension andpain, nausea, and diarrhea. Severe forms of OHSS may causehemoconcentration, thrombosis, elevated white blood count, oliguria,renal failure, pleural effusion, respiratory distress, including acuterespiratory distress syndrome, and even death.

Ovarian hyperstimulation syndrome (OHSS) is a significant complication(side effect) of ART. Ovarian hyperstimulation syndrome (OHSS) isthought to occur as a result of the supraphysiologic agonism of the LHreceptors in the ovary that occur as a result of egg maturationtriggered with human chorionic gonadotropin (acting directly on theovarian LH receptors) and to a lesser extent the GnRH receptor agonists(triggering an endogenous LH surge that is higher than that observed ina normal cycle) in ovaries with a large number of mature follicles. Thecentral feature of clinically significant OHSS is the development ofvascular hyperpermeability causing shifts of fluid. The use of hCGcauses the ovary to undergo extensive luteinization, where large amountsof estrogens, progesterone, and local cytokines are released. ExogenoushCG may have prolonged effects in vivo, and these are likely due toextended over-activation of LH receptors. Vascular endothelial growthfactor (VEGF) production from follicles under the effect of hCG mayincrease vascular hyperpermeability underlying OHSS. Severe OHSS hasbeen reported to occur in up to 2% of the general assisted reproductivepopulation, and in up to 20% of patients at high-risk for developingOHSS, such as patients with polyscystic ovarian syndrome (PCOS).

The use of a GnRH agonist as a trigger agent is associated with lowerrates of OHSS, but also results in lower pregnancy rates, especiallywithout exogenously administered luteal phase support. Protocols usingGnRH agonist triggers require the administration of agents for lutealphase support because the LH surge with these triggers is sharp (e.g., apeak with sufficient amplitude to trigger final maturation, but with ashort wavelength) and short in duration (<20 hours or sometimes 24-36hours). Further, circulating levels of progesterone and estradiol aftera GnRH agonist trigger are significantly lower throughout the lutealphase as compared to those obtained after hCG triggering due to theshorter half-life of LH (˜60 minutes) compared to hCG. Withoutexogenously administered luteal phase support after a GnRH agonisttrigger, premature luteolysis and implantation failure are possible.Further, the risk of OHSS is not completely eliminated by using a GnRHagonist as a trigger agent and frozen embryo transfer in a subsequentmenstrual cycle is still deemed safer to reduce the risk of OHSS.Further there is a desire for women undergoing ART to reduce the time topregnancy, without increasing the risk of OHSS. Currently, it isdifficult to provide the option of a fresh transfer while reducing therisk of OHSS and achieving desirable luteal phase support, oocytematuration yield, pregnancy rates, and live birth rates.

With the need to improve both safety and efficacy, it is desirable tohave new trigger agents for ART, as well as additional agents that maybe administered for luteal phase support.

SUMMARY

The present disclosure relates to methods, uses, and compositions forhelping women with infertility problems. In other aspects, the presentdisclosure relates to elevating levels of endogenous LH in a woman inneed of such elevation. In some aspects, the present disclosure relatesto luteal phase support that provides improved safety and efficacy forthe ART process by offering an alternative to the current methods forthe luteal phase support. The woman may be undergoing ART or may not be.One potential advantage of these improved methods and uses is that, forwomen undergoing ART, they may significantly reduce the risk of OHSS.

One aspect of the disclosure relates to a method of elevating endogenousLH level in a woman in need thereof, the method comprising administeringto the woman an initial dose of about 0.00003 mg to about 0.030 mg of2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide (hereinreferred to as Compound 1), or a corresponding amount of apharmaceutically acceptable salt thereof, wherein the woman isundergoing ART and is at risk for OHSS, and wherein after the initialdose is administered, the woman's endogenous LH level in blood iselevated compared to the woman's endogenous LH level in blood prior toadministration of the initial dose.

Another aspect of the disclosure relates to a method of increasingendogenous LH level in a woman in need thereof undergoing ART, themethod comprising administering to the woman an initial dose of about0.00003 mg to about 0.030 mg of Compound 1, or a corresponding amount ofa pharmaceutically acceptable salt thereof,

wherein the woman is undergoing ART, and wherein at least 36 hours afterthe initial dose is administered, the woman's endogenous LH level inblood is elevated compared to the woman's endogenous LH level in bloodprior to administration of the initial dose.

One aspect of the disclosure relates to a method of increasingendogenous LH level in a woman in need thereof undergoing ART, themethod comprising administering to the woman an initial dose of about0.00003 mg to about 0.030 mg of Compound 1, or a corresponding amount ofa pharmaceutically acceptable salt thereof,

wherein the woman is undergoing ART, and wherein the maximum endogenousLH level in blood occurs at least about 12 hours after administration ofthe initial dose.

Another aspect of the disclosure relates to2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or apharmaceutically acceptable salt thereof, for use in a method ofelevating endogenous LH level in a woman who is undergoing ART and whois at risk for OHSS, the method comprising administering to the woman aninitial dose of about 0.00003 mg to about 0.030 mg of2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or acorresponding amount of the pharmaceutically acceptable salt thereof.

One aspect of the disclosure relates to2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or apharmaceutically acceptable salt thereof, for use in a method ofincreasing endogenous LH level in a woman undergoing ART, the methodcomprising administering to the woman an initial dose of about 0.00003mg to about 0.030 mg of2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or acorresponding amount of the pharmaceutically acceptable salt thereof.

In certain embodiments of any of the foregoing or following, the maximumendogenous LH level in blood occurs between about 12 hours and about 48hours after administration of the initial dose.

Another aspect of the disclosure relates to a method of increasingendogenous LH level in a woman undergoing ART and in need of lutealphase support, the method comprising administering to the woman aninitial dose of about 0.00003 mg to about 0.030 mg of Compound 1, or acorresponding amount of a pharmaceutically acceptable salt thereof,after said woman has received a trigger dose of an oocyte maturationagent as part of an ART regimen.

In certain embodiments of any of the foregoing or following, the woman'sendogenous LH level in blood is elevated between about 12 hours to about96 hours after administration of the initial dose compared to thewoman's endogenous LH level in blood prior to administration of theinitial dose.

In certain embodiments of any of the foregoing or following, the woman'sendogenous LH level in blood is elevated for at least 36 hours afteradministration of the initial dose compared to the woman's endogenous LHlevel in blood prior to administration of the initial dose. In someembodiments, the endogenous LH level in blood is elevated for about 36hours to about 16 days or for about 36 hours to about 12 days.

In certain embodiments of any of the foregoing or following, theadministration of the initial dose promotes oocyte maturation. In someembodiments, oocyte maturation occurs without the administration ofexogenous hCG or exogenous LH. In other embodiments, oocyte maturationoccurs after administration of a GnRH agonist or exogenous hCG. In someembodiments, the yield of mature oocytes is at least 50%.

In certain embodiments of any of the foregoing or following, afteradministration of the initial dose, the woman does not experience one ormore symptoms selected from the group consisting of ascites, pleuraleffusion and reduced renal perfusion. In some embodiments, afteradministration of the initial dose, ovary size may not increase togreater than 5 cm in diameter.

In certain embodiments of any of the foregoing or following, the womandoes not experience one or more symptoms of OHSS after administration ofthe initial dose. In some embodiments, after administration of theinitial dose, the woman does not experience a worsening of one or moresymptoms of OHSS.

In certain embodiments of any of the foregoing or following, the initialdose is administered when at least three ovarian follicles of at least14 mm are visible via ultrasound or when at least three ovarianfollicles of at least 18 mm are visible via ultrasound.

In certain embodiments of any of the foregoing or following, the initialdose is administered when serum estradiol concentration is at least 0.49nmol/L.

In certain embodiments of any of the foregoing or following, the methodor use further comprises administration of FSH about 5 days to about 12days prior to administration of the initial dose.

In certain embodiments of any of the foregoing or following, the methodor use further comprises administration of a GnRH antagonist about 2days to about 10 days prior to administration of the initial dose. Insome embodiments, the GnRH antagonist is selected from the groupconsisting of relugolix, elagolix, cetrorelix, ganirelix, abarelix,nal-blu, antide, azaline B, degarelix, D63153 (ozarelix), OBE2109, andteverelix. In some embodiments, the method or use further comprisesadministration of a GnRH agonist from about 14 to about 28 days prior toadministration of the initial dose. In certain embodiments of any of theforegoing or following, the GnRH agonist is selected from the groupconsisting of leuprorelin acetate, gonadorelin, buserelin, triptorelin,goserelin, nafarelin, histrelin, deslorelin, meterelin, and lecirelin.

In certain embodiments of any of the foregoing or following, the initialdose is administered prior to oocyte retrieval, after oocyte retrieval,prior to ovulation, or after ovulation. In some embodiments, the initialdose is administered after administration of a GnRH agonist as an oocytematuration agent.

In certain embodiments of any of the foregoing or following, wherein themethod or use further comprises administering a second dose of about0.00003 mg to about 0.030 mg of Compound 1, or a corresponding amount ofa pharmaceutically acceptable salt thereof. In some embodiments, thesecond dose is administered within about 8 to about 60 hours afteradministration of the initial dose.

In certain embodiments of any of the foregoing or following, the methodor use further comprises administering a third dose of about 0.00003 mgto about 0.030 mg of Compound 1, or a corresponding amount of apharmaceutically acceptable salt thereof. In some embodiments, the thirddose is administered within about 8 to about 60 hours afteradministration of the second dose.

In certain embodiments of any of the foregoing or following, the methodsand uses further comprise administration of one to five additional dosesof about 0.00003 mg to about 0.030 mg of Compound 1, or a correspondingamount of a pharmaceutically acceptable salt thereof. In someembodiments, the administration of the one to five additional doses iswithin about 8 to about 60 hours after the prior additional dose isadministered. In some embodiments, one or more of the initial dose,second dose, third dose, or one to five additional doses promotes lutealphase support. In some embodiments, one or more of the initial dose,second dose, third dose, or one to five additional doses areadministered via injection. In certain such embodiments, the injectionis an intramuscular or subcutaneous injection. In certain embodiments ofany of the foregoing or following, any one or more of the initial dose,second dose, third dose, or one to five additional doses is from about0.0003 mg to about 0.03 mg.

In certain embodiments of any of the foregoing or following, the methodor use further comprises administering one or more doses of aprogestogen. In certain embodiments of any of the foregoing orfollowing, the method or use does not comprise administering one or moredoses of a progestogen.

In certain embodiments of any of the foregoing or following, the methodor use further comprises oocyte retrieval.

In certain embodiments of any of the foregoing or following, the woman'spituitary is desensitized to GnRH prior to administration of the initialdose.

In certain embodiments of any of the foregoing or following, the methodor use further comprises implantation of an embryo. In some embodiments,the implantation occurs within about 2 to about 10 days afteradministration of the initial dose. In some embodiments, theimplantation occurs within about 1 to about 7 days after oocyteretrieval. In some embodiments, the embryo has not been frozen. In someembodiments, the embryo is implanted within the same menstrual cycle asoocyte retrieval.

In certain embodiments of any of the foregoing or following, the methodor use induces ovulation.

In certain embodiments of any of the foregoing or following, the womanconceives via intercourse or IUI after administration of at least theinitial dose. In some embodiments, after administration of at least theinitial dose, the woman conceives and/or gives birth.

In certain embodiments of any of the foregoing or following, the womanis undergoing COS. In some embodiments, the woman has one or more ofPCOS, serum anti-Müllerian hormone (AMH) greater than 15 pmol/L, totalantral follicle count (AFC) greater than 23 via ultrasound, serumestradiol E2 greater than 3000 pg/mL, or has experienced one or moreprevious episodes of OHSS. In some embodiments, the woman is any one ormore of anovulatory, or of advanced maternal age, or is experiencingsecondary ovarian failure, oligomenorrhea, amenorrhea, endometriosis, orPCOS.

In certain embodiments of any of the foregoing or following, the ARTtherapy is selected from the group consisting of oocyte donation, oocytebanking, intracytoplasmic sperm injection (ICSI), IVF, embryo transfer(ET) process, ovulation induction, and IUI.

One aspect of the disclosure relates to a method of inducing finalfollicular maturation and early luteinization in a woman in needthereof, wherein said woman is undergoing ART, has undergone pituitarydesensitization and has been pretreated with follicle stimulatinghormones as part of ART, said method comprising administering to thewoman an initial dose of about 0.00003 mg to about 0.030 mg of Compound1, or a corresponding amount of a pharmaceutically acceptable saltthereof, and wherein after the initial dose is administered, the woman'sendogenous LH level in blood is elevated compared to the woman'sendogenous LH level in blood prior to administration of the initialdose.

Another aspect of the disclosure relates to a method of inducingovulation in a woman in need thereof, wherein said woman is anovulatoryinfertile and wherein said infertility is not due to primary ovarianfailure, said method comprising administering to the woman an initialdose of about 0.00003 mg to about 0.030 mg of Compound 1, or acorresponding amount of a pharmaceutically acceptable salt thereof, andwherein after the initial dose is administered, the woman's endogenousLH level in blood is elevated compared to the woman's endogenous LHlevel in blood prior to administration of the initial dose.

Another aspect of the disclosure relates to2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or apharmaceutically acceptable salt thereof for use in a method of inducingfinal follicular maturation and early luteinization in a woman who isundergoing ART, has undergone pituitary desensitization and has beenpretreated with follicle stimulating hormones as part of ART, saidmethod comprising administering to the woman an initial dose of about0.00003 mg to about 0.030 mg of2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or acorresponding amount of the pharmaceutically acceptable salt thereof.

One aspect of the disclosure relates to2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or apharmaceutically acceptable salt thereof for use in a method of inducingovulation in a woman who is anovulatory infertile, wherein saidinfertility is not due to primary ovarian failure, said methodcomprising administering to the woman an initial dose of 0.00003 mg toabout 0.030 mg of2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or acorresponding amount of the pharmaceutically acceptable salt thereof.

In certain embodiments of any of the foregoing or following, the womanis at risk for OHSS.

In certain embodiments of any of the foregoing or following, the womanexperiences anovulatory infertility not due to primary ovarian failure.

In certain embodiments of any of the foregoing or following, the methodsand uses comprise administering to the woman an initial dose of about0.001 mg to about 0.003 mg, about 0.001 mg to about 0.030 mg, or about0.0003 mg to about 0.003 mg of Compound 1, or a corresponding amount ofa pharmaceutically acceptable salt thereof.

One aspect of the disclosure relates to use of2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or apharmaceutically acceptable salt thereof, for the manufacture of amedicament for elevating endogenous LH level in a woman who isundergoing ART and who is at risk for OHSS.

Another aspect of the disclosure relates to use of2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or apharmaceutically acceptable salt thereof, for the manufacture of amedicament for increasing endogenous LH level in a woman undergoing ART.

One aspect of the disclosure relates to use of2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or apharmaceutically acceptable salt thereof, for the manufacture of amedicament for inducing final follicular maturation and earlyluteinization in a woman who is undergoing ART, has undergone pituitarydesensitization and has been pretreated with follicle stimulatinghormones as part of ART.

Another aspect of the disclosure relates to use of2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or apharmaceutically acceptable salt thereof, for the manufacture of amedicament for inducing ovulation in a woman who is anovulatoryinfertile, wherein said infertility is not due to primary ovarianfailure.

Further embodiments of the present disclosure are described hereinafter,in which some, but not all, embodiments of the disclosure areillustrated.

Each embodiment disclosed herein may be used individually or incombination with any other embodiment disclosed herein.

Publications, patents, and published patent applications referred to inthis application are specifically incorporated by reference herein.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 shows an illustrative schematic of an ART protocol. Thisschematic is not meant to be limiting.

FIG. 2 provides plots depicting mean plasma concentrations of Compound 1monoacetate (API-MA) up to 72 hours by treatment group when administeredto healthy European men as described in Example 5.

FIG. 3 is a plot depicting mean (±standard deviation [SD]) Compound 1monoacetate (API-MA) concentration in plasma-time profiles after 2-hoursubcutaneous (SC) administration of 0.5 and 1.0 mg/day API-MA for 14days in healthy European men as described in Example 6.

FIG. 4 is a plot depicting mean plasma concentration-time curves by dosegroup: Day 1 up to 12 hours in European men with prostate cancer asdescribed in Example 7 using a SC depot injection.

FIG. 5 is a plot depicting mean plasma concentration-time curves by dosegroup: Month 1, Day 2 through month 3 in European men with prostatecancer as described in Example 7 using a SC depot injection.

FIG. 6 is a plot depicting mean (SD) serum LH concentrations following asingle SC bolus of API-MA in European men with prostate cancer asdescribed in Example 7.

FIG. 7 is a plot depicting mean (SD) serum FSH concentrations followinga single SC bolus of API-MA as described in Example 7.

FIG. 8 is a plot depicting mean serum concentration-time profiles of LHas described in Example 7.

FIG. 9 is a plot depicting mean serum concentration-time profiles of FSHas described in Example 7.

FIG. 10 is a plot depicting mean serum concentration of LH followingAPI-MA administered by SC bolus (day 1) and continuous SC infusion (Days2-14) as described in Example 8.

FIG. 11 is a plot depicting mean serum concentration of FSH followingAPI-MA administered by SC bolus (Day 1) and continuous SC INF (Days2-14) as described in Example 8.

FIG. 12 is a plot depicting LH by subject (N=3) in the API-MA 0.5 mg/daygroup as described in Example 8.

FIG. 13 is a plot depicting FSH by subject (N=3) in the API-MA 0.5mg/day group as described in Example 8.

FIG. 14 illustrates the study design detailed in Example 11, Part 1.

FIGS. 15A, 15B, and 15C illustrate the changes in LH, FSH, oestradiol,and progesterone over 48 hours after administration of 9.6 nmol/kgkisspeptin-54 (KP54), 0.003 nmol/kg Compound 1, and 0.03 nmol/kgCompound 1 to healthy women ages 18-35 as described in Example 11.

FIGS. 16A, 16B, and 16C illustrate the changes in LH over 48 hours afteradministration of 9.6 nmol/kg kisspeptin-54 (KP54), 0.003 nmol/kgCompound 1, and 0.03 nmol/kg Compound 1 to healthy women ages 18-35 asdescribed in Example 11.

FIG. 17 illustrates the average changes in LH for all subjects over 48hours after administration of 9.6 nmol/kg kisspeptin-54 (KP54), 0.003nmol/kg Compound 1, and 0.03 nmol/kg Compound 1 to healthy women ages18-35 as described in Example 11.

FIG. 18 illustrates the average changes in LH for all subjects over 48hours after administration of 0.003 nmol/kg Compound 1 to healthy womenages 18-35 as described in Example 11.

FIG. 19 illustrates the average changes in LH for all subjects over 48hours after administration of 0.03 nmol/kg Compound 1 to healthy womenages 18-35 as described in Example 11.

FIGS. 20A and 20B illustrate the changes in FSH and oestradiol over 48hours after administration of 9.6 nmol/kg kisspeptin-54 (KP54), 0.003nmol/kg Compound 1, and 0.03 nmol/kg Compound 1 to healthy women ages18-35 as described in Example 11.

DETAILED DESCRIPTION

Assisted reproductive technology (ART) is complex, with each assistedreproduction cycle consisting of several, carefully orchestrated steps.If any of these steps are improperly performed, conception or pregnancymay fail. Additionally, the success of ART protocols varies greatly fromwoman to woman, adding to the complexity. The typical phases of ARTinclude an initial COS phase to promote and stimulate the controlledgrowth and development of ovarian follicles, followed by the use of aso-called “trigger” agent to promote/induce the final maturation ofoocytes. In some ART regimens, the mature oocytes may then be retrievedfrom the ovarian follicles, fertilized in vitro or by ICSI, and theembryo(s) transferred to the uterus or, instead of retrieving the eggsfrom the ovarian follicles, ovulation occurs and the mature oocytes maybe fertilized via intercourse or IUI. A schematic of a representativeART regimen is provided in FIG. 1. As ART procedures are invasive,expensive, and may have negative side effects, preventing or reducingthe possibility of conception failure or pregnancy failure is important.

For example, as schematically depicted in FIG. 1, administration of longGnRH agonist treatment, to suppress the LH surge, begins in themenstrual cycle prior to the menstrual cycle in which the trigger agentwill be administered. Administration of the GnRH agonist may be incombination with FSH or FSH/hMG treatment, to stimulate the follicles,or FSH or FSH/hMG treatment in the absence of long GnRH agonisttreatment may begin the ART treatment protocol. Alternatively, a GnRHantagonist may be used instead of a GnRH agonist to suppress the LHsurge and is used in combination with FSH or FSH/hMG treatment. In thiscase, the GnRH antagonist is administered within the same menstrualcycle and after FSH or combination FSH/hMG treatment has commenced.Treatment may then be followed by administration of a trigger, typicallya GnRH agonist, hCG, or, as detailed in this disclosure, Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing. Human chorionic gonadotropin (hCG) has LH-like activity whichacts on LH receptors and causes ovulation. Typically 30 to 62 hoursafter administration of the trigger, oocyte retrieval or ovulationoccurs. The human female subject undergoing ART may then be treated withIUI or have intercourse to become pregnant. After the trigger andthrough ET, IUI, or intercourse, the human female subject may or may notreceive luteal phase support, including, but not limited to,administration of low dose hCG, a progestogen, estradiol, or Compound 1,a metabolite thereof, or a pharmaceutically acceptable salt of any ofthe foregoing.

Disclosed herein are ART methods and uses comprising administration ofCompound 1, a metabolite thereof, or a pharmaceutically acceptable saltof any of the foregoing. As used herein, Compound 1 is2-(N-Acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-Lasparaginyl-L-threonyl-L-phenylalanyl)-hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide.Compound 2 is a metabolite of Compound 1. Compound 1, a metabolitethereof, or a pharmaceutically acceptable salt of any of the foregoingmay mimic natural physiology by inducing the release of endogenous LHduring assisted reproduction, thereby possibly enhancing the likelihoodof successful egg (oocyte) maturation and, in some cases, ovulation atthe right time during the cycle without the potential for serious sideeffects associated with current hormone-stimulation treatment options,such as hCG. Previous studies with Compound 1 were conducted in men oranimals, such as rats, dogs, and monkeys, to assess Compound 1'spharmacokinetic properties or efficacy in the treatment of prostatecancer. The bioavailability of Compound 1 was quite different in rats(66.3%) versus dogs (92.4%). The enhancement of subcutaneous first-passmetabolism caused non-linear pharmacokinetics of Compound 1 after asingle subcutaneous (SC) administration to rats. Compound 1 showed lessthan dose-proportional non-linear pharmacokinetics with a reduction ofthe AUC after SC administration in a dose range of 1 mg/kg and 10 mg/kgto rats. Less than dose-proportional non-linear pharmacokinetics wereobserved after SC administration with limited absorption of Compound 1at the highest dose level contrary to the linear pharmacokineticsfollowing IV dosing, indicating an enhancement of SC metabolism withdose escalation. The systemic absorption of Compound 1 recovered whenprotease inhibitors were subcutaneously co-administered, suggesting theinvolvement of SC proteases in the first-pass metabolism. The top humandose given to men via SC bolus was only approximately 0.008 mg/kg andexposure was dose proportional up to this dose. SC infusions were alsoproportional up to approximately 0.1 mg/kg. A depot formulation resultedin less than proportional exposure over approximately 0.1 mg/kg to 0.4mg/kg. The present disclosure describes the use of Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, in women to assist with ART. The doses of Compound 1 usedherein are much lower than those tested in rats and in men, with amaximum dose of 30 or 0.25 μg/kg compared to 1 mg/kg and 10 mg/kg inrats and 8 μg/kg and 0.1 mg/kg to 0.4 mg/kg in men.

Compound 1, a metabolite thereof, or a pharmaceutically acceptable saltof any of the foregoing, may not only facilitate the maturation, release(ovulation), and retrieval of fresh mature oocytes (or eggs, usedinterchangeably herein) from the ovaries, leading to similar or improvedoverall pregnancy rates versus an hCG trigger, but also, maysignificantly mitigate the risk of key side effects, like OHSS, comparedto hCG and GnRH agonists. Additionally, compared to currently availabletrigger agents (particularly, hCG-based trigger agents), Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, may provide an advantage of significantly reducing the rateof OHSS in all patients, including those with elevated levels of AMR orpatients with FSH and LH receptor mutation sensitivity. Further,Compound 1, a metabolite thereof, or a pharmaceutically acceptable saltof any of the foregoing, may provide luteal phase support by activatingthe LH surge to a natural peak and with a long duration (>20 hours,mimicking the natural LH surge of 48 hours) with a low risk of OHSS.This benefit of Compound 1, a metabolite thereof, or a pharmaceuticallyacceptable salt of any of the foregoing, may eliminate the need foradditional luteal phase support, such as daily IM progesteroneinjections or additional hCG supplementation, simplifying ART protocolsand also allowing for the implantation of “fresh” embryos during thesame menstrual cycle, potentially reducing the time to pregnancy.

Compared to currently available trigger agents, Compound 1, a metabolitethereof, or a pharmaceutically acceptable salt of any of the foregoing,may provide an advantage of shorter time to pregnancy. Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, may afford increased rates of fresh embryo transfer, reducingthe need for segmentation (freezing the egg or embryo between retrievaland implantation). Due to the mode of action of Compound 1, a metabolitethereof, or a pharmaceutically acceptable salt of any of the foregoing,there may be less negative impact on the endometrium compared to currenttreatments. Thus, the endometrium may be ready for implantation (higherendometrial receptivity) immediately after egg (oocyte) retrieval. Thismay allow for implantation within the same menstrual cycle as triggeringand oocyte retrieval. Compared to hCG-based trigger agents (includingdual triggers with GnRH agonists), Compound 1, a metabolite thereof, ora pharmaceutically acceptable salt of any of the foregoing, may resultin less need for a segmentation freezing protocol, thereby reducing thenumber of IVF cycles; shortening time to pregnancy, while maintainingacceptable pregnancy rates; lowering costs; and reducing side effects,such as macrosomia (large for gestational age), placenta accreta, andpreeclampsia, all with significantly lower OHSS rates. Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, may provide safety and efficacy attributes that represent anadvantage compared to current treatments that require segmentation.

The present disclosure also relates to methods and uses comprisingadministration of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, for increasingendogenous LH levels in a human female subject undergoing ART, such asin IVF, ICSI, oocyte donation and banking, regulation of a menstrualcycle so a human female subject may conceive via intercourse or IUI,ovulation induction, and/or in an ET process. An increase in endogenousLH levels may assist in both oocyte maturation and luteal phase support.

The present disclosure further relates to methods and uses comprisingadministration of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, for inhibitingovulation and the premature release of oocytes during the initial COSphase. These methods and uses may be applicable to ART protocols thatutilize either a gonadotropin-releasing hormone (GnRH) agonist orantagonist during the initial COS phase.

Provided herein is the use of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, for themanufacture of a medicament for treatment according to any of methodsdescribed herein. Provided also is Compound 1, a metabolite thereof, ora pharmaceutically acceptable salt of any of the foregoing, for use inany of the methods described herein.

Compounds of the Disclosure

As used herein, Compound 1 is2-(N-Acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)-hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide.The molecular formula is C₅₈H₈₀N₁₆O₁₄ and the molecular weight is1225.35. Compound 1 is a free form and represented by the sequence:

Ac-D-Tyr-Hyp-Asn-Thr-Phe-AzaGly-Leu-Arg(Me)-Trp-NH₂ (SEQ ID NO. 1), andby the structural formula:

In some embodiments, the compound of the disclosure is a metabolite ofCompound 1. In certain such embodiments, the metabolite is Compound 2,represented by the following structural formula:

In some embodiments, a pharmaceutically acceptable salt of Compound 1and/or a metabolite thereof is used. “Physiologically acceptable,”“pharmaceutically acceptable,” or “pharmacologically acceptable”compounds and compositions may include materials which are notbiologically, or otherwise, undesirable. For example, the material maybe administered to an individual without causing any substantiallyundesirable biological effects or interacting in a deleterious mannerwith any of the components of the composition in which it is contained.In certain embodiments, the pharmaceutically acceptable salt of Compound1 and/or a metabolite thereof is a pharmaceutically acceptable acidaddition salt. Such salts include, but are not limited to, salts withinorganic acids (e.g., hydrochloric acid, hydrobromic acid, nitric acid,sulfuric acid, phosphoric acid, and the like) and salts with organicacids (e.g., formic acid, acetic acid, trifluoroacetic acid, fumaricacid, oxalic acid, tartaric acid, maleic acid, citric acid, succinicacid, malic acid, methanesulfonic acid, benzenesulfonic acid,p-toluenesulfonic acid, and the like). In certain embodiments, thepharmaceutically acceptable salt of Compound 1 and/or a metabolitethereof is a pharmaceutically acceptable basic addition salt. Such saltsinclude, but are not limited to, an inorganic base (e.g., alkali metalsand alkaline earth metals such as sodium, potassium, calcium, magnesium,ammonia, and the like) or an organic base (e.g., trimethylamine,triethylamine, pyridine, picoline, ethanolamine, diethanolamine,triethanolamine, dicyclohexylamine, N,N′-dibenzylethylenediamine, andthe like).

As used herein, a form of Compound 1 is2-(N-Acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-Lasparaginyl-L-threonyl-L-phenylalanyl)-hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamidemonoacetate. For the monoacetate salt, the molecular formula isC₅₈H₈₀N₁₆O₁₄.C₂H₄O₂ and the molecular weight is 1285.41. The structuralformula is the following:

Throughout the present disclosure, amounts of Compound 1, or ametabolite thereof, refer to the amount of Compound 1 free form presentin the formulation. The term “corresponding amount” as used hereinrefers to the amount of a pharmaceutically acceptable salt of Compound1, or a metabolite thereof, required to obtain the amount of Compound 1,or a metabolite thereof, free form recited in the formulation. It wouldbe clear to one of skill in the art how to calculate the “correspondingamount” of the salt of a compound, such as the corresponding amount ofthe pharmaceutically acceptable salt of Compound 1, taking into accountthe difference in molecular weight between the free form of a compoundand a salt form. For example, 10.0 mg of compound free form, wouldcorrespond to 10.5 mg of the monoacetate salt.

Compound 1, or a pharmaceutically acceptable salt thereof, andpharmaceutical compositions containing Compound 1, or a pharmaceuticallyacceptable salt thereof, may be produced by methods described in U.S.Pat. Nos. 7,960,348 and 8,404,643, the disclosures of which are hereinincorporated by reference.

Compound 1 has been described as a kisspeptin analog. Kisspeptin, ahypothalamic neuropeptide encoded by the KISS1 gene, is a centralregulator of GnRH secretion and a recently discovered hormone which isvital for normal puberty. Kisspeptin is a peptide ligand agonist of thehuman G-protein-coupled receptor 54 (GPR54)/KISS1 receptor (KISS1R)(formerly known as OT7T175/GPR54). Mutations of or knock out of theKISS1R gene result in defective onset of puberty. In the hypothalamus,kisspeptin plays a key role in regulating the amount and pulsatility ofgonadotropin-releasing hormone (GnRH) secretion. Administration ofkisspeptin in mammals, including humans, induces GnRH and gonadotropinrelease, and this effect is most plausibly a direct effect of thepeptide on the GnRH neurons. GnRH is the key component of thehypothalamic-pituitary-gonadal axis and controls the reproductivefunctions, such as spermatogenesis, follicular maturation and ovulation,and steroidogenesis. Therefore, kisspeptin is a critical regulator ofthe hypothalamic-pituitary-gonadal axis via controlling GnRH neurons.There are two modes of GnRH secretion. One mode is pulsatile GnRHsecretion that mainly regulates spermatogenesis, folliculogenesis, andsteroidogenesis, which is feedback (negatively) regulated by steroidalhormones. The other mode is GnRH surge, resulting in an LH surge that isobserved in females only, and induces final maturation of oocytes and,eventually, ovulation. Kisspeptin neurons in the hypothalamus canregulate both modes of GnRH secretion. Pharmacologically, in multiplespecies, including humans, acute kisspeptin exposure may stimulateGnRH-gonadotropin secretion, whereas chronic (higher dose) kisspeptinexposure may suppress GnRH secretion and thehypothalamic-pituitary-gonadal-axis due to potential mechanisms ofsuppression, such as desensitization of GnRH receptors and/or depletionof GnRH reserves. Chronic administration of kisspeptin analogssuppresses intrinsic GnRH pulses and downstream pituitary gonadalfunctions. This may be due to the attenuation of the responsiveness ofGnRH neurons to endogenous kisspeptin stimulation and the stimulation ofGnRH neurons to release low levels of GnRH continuously.

Kisspeptin-54 has a half-life of 32 minutes and it stimulates therelease of endogenous GnRH, which then stimulates gonadotropin releaseand subsequently sex hormones. Kisspeptin administration to healthyhuman male and female volunteers was shown to significantly increaseplasma LH, FSH, and testosterone concentrations, and subcutaneousadministration of kisspeptin to human female volunteers increased plasmaLH in all phases of the menstrual cycle. The effect of kisspeptin wasgreatest in the pre-ovulatory phase, when trigger agents are typicallyadministered, and least in the follicular phase of the cycle. Kisspeptinwas also experimentally tried as a trigger in an ART protocol comprisinga GnRH antagonist and FSH in both an IVF population of women and a highrisk OHSS IVF population. Kisspeptin has only been used as a trigger inART cycles using a GnRH antagonist protocol. Accordingly, an increasedluteal phase defect may occur with kisspeptin ART protocols as GnRHantagonist protocols typically result in luteal phase defects when hCGis not the trigger. Kisspeptin was found to stimulate endogenous levelsof LH, however, the duration of the LH surge was much shorter than thesurge observed with hCG or GnRH agonist triggers, leading to the needfor additional exogenous luteal phase support. With kisspeptin-54, theLH surge resolved by 36 hours. In some women, the full LH surge was notobserved, thereby reducing oocyte yields. Further, higher doses ofkisspeptin led to lower pregnancy rates and the ideal dose is not yetknown. Additional studies reported in Example 11 (FIGS. 15A and 16A)indicate that female subjects receiving kisspeptin-54 during thefollicular phase (when LH levels are least affected by trigger agents)experienced an increase in LH peaking around 4-6 hours afteradministration of the kisspeptin trigger, with the LH surge lasting lessthan 14 hours. Despite its drawbacks, studies with kisspeptin-54 didindicate that fresh embryo transfer (transfer within the same menstrualcycle) is possible in high risk OHSS women.

Compound 1, or a pharmaceutically acceptable salt thereof, has ahalf-life of up to four hours. As shown in Example 11 (FIGS. 16B, 17,and 18), after administration of a 0.003 nmol/kg Compound 1(approximately 0.00022 mg) dose during the follicular phase in women(when LH levels are least affected by trigger agents), peak serum LHlevels are estimated to occur between 14-36 hours post-dosing and the LHsurge lasted at least about 48 hours, the duration of the natural LHsurge. Thus, administration of Compound 1, or a pharmaceuticallyacceptable salt thereof, may potentially be able to not only triggerfinal oocyte maturation, but also able to provide luteal support and,therefore, enhance the likelihood of successful implantation.Surprisingly, the LH surge observed with Compound 1 had a curve similarto that of the natural LH surge, being broader than the LH surgesinduced by GnRH agonist triggers, and potentially longer lasting. It wasalso surprising that Compound 1 had such a robust impact on LH levelsduring the follicular phase in women. As its impact was greater thanthat of kisspeptin-54, this indicates that Compound 1 should also causea dramatic increase in LH levels during the pre-ovulatory phase,potentially greater both in amplitude and duration than those observedwith kisspeptin-54 during the pre-ovulatory phase. As used herein, thepre-ovulatory phase may refer to the time period 15 to 16 days beforethe start of a woman's next predicted period.

Due to the nature of the LH surge observed with Compound 1, which moreclosely mimics the natural surge, it, or a metabolite thereof, may be anideal agent for inclusion into ART protocols. Administration of Compound1, a metabolite thereof, or a pharmaceutically acceptable salt of any ofthe foregoing, as a trigger could limit the need for luteal phasesupport. It could also allow for the option of fresh transfer ofembryos, greatly shortening the time to pregnancy and the costsassociated with multiple rounds of ART.

An additional advantage of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, over currenttreatments is that its effects will depend upon the endogenous releaseof a woman's GnRH pool. This may result in a more physiologicstimulation of gonadotropins and prevent excessive stimulation, whichlimits current fertility treatments. As Compound 1, or a metabolitethereof, stimulates the release of endogenous LH into the woman'scirculation, there is far less likelihood of potentiallylife-threatening OHSS.

Methods of Treatment and Uses of the Compounds of the Disclosure

The present disclosure provides for methods and uses for elevatingendogenous LH level in a woman in need thereof comprising administeringto the woman an initial dose of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing. In someembodiments, the woman is undergoing ART and is at risk for OHSS. Incertain such embodiments, after the initial dose is administered, thewoman's endogenous LH level in blood is elevated compared to the woman'sendogenous LH level in blood prior to administration of the initialdose.

Throughout the disclosure, the doses or amounts of Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing (for example, about 0.00003 mg to about 0.030 mg, about 0.0003to about 0.003 mg, about 0.001 mg to about 0.003 mg, or about 0.001 mgto about 0.03 mg of Compound 1, or a corresponding amount of apharmaceutically acceptable salt thereof), used in any of the methods oruses disclosed herein may be any of the doses or amounts disclosedherein below. Additionally, the formulations or pharmaceuticalcompositions comprising Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, used in any ofthe methods and uses disclosed herein may be any of the formulations orpharmaceutical compositions disclosed herein below. The doses andamounts of Compound 1, a metabolite thereof, or a pharmaceuticallyacceptable salt of any of the foregoing, and formulations orpharmaceutical compositions comprising Compound 1, a metabolite thereof,or a pharmaceutically acceptable salt of any of the foregoing, disclosedherein may be administered by any of the methods of administrationdisclosed herein.

Herein, the woman's endogenous LH level in blood prior to administrationof the initial dose may be computed as the mean of five LH valuesimmediately preceding the designated day of onset of the LH surge (i.e.,5 days preceding administration of Compound 1, a metabolite thereof, ora pharmaceutically acceptable salt of any of the foregoing). Elevatingwould be an increase above the woman's endogenous LH level in bloodprior to administration of the initial dose. The end of elevation wouldbe when the LH levels returns to the woman's endogenous LH level inblood prior to administration of the initial dose. As used herein, theLH peak is the highest LH value, the LH amplitude is the differencebetween the peak LH value and the woman's endogenous LH value in bloodprior to administration of the initial dose, and the LH surge foldincrease is the peak LH value divided by the woman's endogenous LH valuein blood prior to administration of the initial dose. In the setting ofCOS, the woman's endogenous LH value in blood prior to administration ofthe initial dose ranges from 2-10 IU/L, with a peak range of LH surgebetween 20 to 120 IU/L, (Amplitude=peak−the woman's endogenous LH levelin blood prior to administration of the initial dose). The fold increaseis typically between 2 times and 60 times. In most women, a 2 times to11 times fold increase in LH is expected (when done in COS setting orpre-ovulatory phase).

As will be appreciated by the skilled artisan, the success of ARTregimens may depend on both the timing and dosage of administration ofvarious agents throughout the treatment regimen and during variousphases of a woman's menstrual cycle. As described herein, the variousregimen depend on careful administration of agents including FSH orFSH/hMG to induce oocyte maturation and also the administration ofadditional agents (e.g., GnRH agonists or antagonists) at specific timesduring the menstrual cycle and in certain doses to ensure that multipleoocytes are maturing within a similar period such that after theadministration of the trigger agent, oocytes that have undergone finalmaturation are available for retrieval before premature ovulation foruse in e.g., oocyte banking, oocyte donation, IVF, ICSI, etc., or areallowed to ovulate and are subsequently fertilized by IUI or intercoursewithin a specified time after projected ovulation. Important to all ofthese aspects of ART is the control of LH levels. For example, theremust be enough LH present to stimulate (“trigger”) final maturation ofmultiple oocytes within a given time period and in sufficient quantityto result in oocyte yield high enough for successful oocyte retrieval(e.g., sufficient oocyte yield) and therefore available for ICSI or IVF.Additionally, where ET is contemplated, particularly within the samemenstrual cycle, there needs to be an elevated level of LH sufficient tocontinue production of progesterone from the corpus luteum to helpensure support of the endometrium (also referred to as luteal support)and thereby enhance the likelihood of successful implantation of theembryo, thus leading to successful pregnancy and live birth. Similarly,where ovulation takes place followed by IUI or intercourse, lutealsupport and a receptive endometrium are also important for the samereasons. Based on control of the timing of administration and doseadministered of Compound 1, a metabolite thereof, or a pharmaceuticallyacceptable salt of any of the foregoing, in order to increase a woman'sendogenous LH levels at the right amount and at the right time, Compound1, a metabolite thereof, or a pharmaceutically acceptable salt of any ofthe foregoing, may be safely employed in various ART regimens describedherein. As described herein, the use of Compound 1, a metabolitethereof, or a pharmaceutically acceptable salt of any of the foregoing,elevates the endogenous LH level in blood. As the source of the LH isthe woman's own pituitary gland, instead of exogenous LH or an agentthat agonizes the LH receptor, the risk of stimulatingsupraphysiological amounts of LH (e.g., overstimulating) that may leadto OHSS or other complications is greatly reduced, while also allowingfor high oocyte yield at oocyte retrieval and supporting successfulimplantation during ET.

The present disclosure includes methods and uses comprisingadministration of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, in assistedreproductive technologies, such as IVF, ICSI, oocyte donation andbanking, regulation of a menstrual cycle so a human female subject mayconceive via intercourse or intrauterine insemination (IUI), ovulationinduction, and/or in an ET process.

As used herein, “in vitro fertilization” (IVF) may refer to a methodcomprising collecting an ovum, fertilizing the ovum in vitro with aspermatozoon and, when cleavage has progressed to a certain degree,inserting the ovum into the uterine cavity. That is, it may include theprocesses of ovulation induction, ovum collection, IVF and culture, andembryo transfer. In IVF, induction of final maturation may allow for egg(oocyte) retrieval when the eggs (oocytes) are fully mature. Further, inIVF, final maturation induction may be preceded by COS.

“Embryo transfer” may refer to, within the IVF processes, the process ofimplanting an embryo in the uterine cavity. One to several embryosinserted into the uterine cavity may be implanted in the uterus, therebypossibly resulting in pregnancy. The term may also encompass frozenembryo transfer and gamete intrafallopian transfer (GIFT) that do notinvolve in vitro fertilization. “An embryo transfer process” may referto the entire period during which insertion of an embryo or gamete intothe uterine cavity, a sequence of processes of implantation of theembryo or gamete in the uterus and pregnancy, drug administration beforeand after embryo transfer to achieve pregnancy, and the like areperformed.

“Intracytoplasmic sperm injection” (ICSI) may refer to the laboratoryprocedure where a single sperm is picked up with a fine glass needle andis injected directly into each egg. In conventional IVF, the eggs andsperm are mixed together in a dish and the sperm fertilizes the egg‘naturally.’ However to have a chance that this will occur, largenumbers of actively swimming normal sperm are required. For manycouples, the number of suitable sperm available may be very limited orthere may be other factors preventing fertilization, so conventional IVFis not an option, but ICSI is. ICSI refers to the laboratory procedurewhere a single sperm is picked up with a fine glass needle and isinjected directly into each egg. This is carried out in the laboratoryby experienced embryologists using specialist equipment. Very few spermare required and the ability of the sperm to penetrate the egg is nolonger important as this has been assisted by the ICSI technique. ICSIdoes not guarantee that fertilization will occur as the normal cellularevents of fertilization still need to occur once the sperm has beenplaced in the egg.

In some embodiments of the methods and uses described herein, the ART isoocyte donation. In some embodiments of the methods and uses describedherein, the ART is oocyte banking. In some embodiments of the methodsand uses described herein, the ART is ICSI. In some embodiments of themethods and uses described herein, the ART is IVF. In some embodimentsof the methods and uses described herein, the ART is an ET process. Insome embodiments of the methods and uses described herein, the ART isovulation induction. In some embodiments of the methods and usesdescribed herein, the ART is IUI. In some embodiments of the methods anduses described herein, the ART is regulation of a menstrual cycle so ahuman female subject may conceive via intercourse.

The human female subjects of the methods and uses described herein mayinclude women trying to get pregnant. The human female subjects of themethods and uses described herein may include women trying to ovulate.The human female subjects of the methods and uses described herein mayinclude women trying to donate or bank oocytes (e.g., egg donors). Thehuman female subjects of the methods and uses described herein mayinclude women trying to act as surrogates. The human female subjects ofthe methods and uses described herein may include women undergoing COS.The human female subjects of the methods and uses described herein mayalso include women at risk for OHSS. The human female subjects of themethods and uses described herein may also include women who areinfertile; anovulatory; of advanced maternal age (i.e., over 35 years ofage); or experiencing secondary ovarian failure, oligomenorrhea,amenorrhea, endometriosis, or polyscystic ovarian syndrome (PCOS); orcombinations of any of the foregoing. The human female subjects of themethods and uses described herein may include women experiencinganovulatory infertility not due to primary ovarian failure. The humanfemale subjects of the methods and uses described herein may includewomen experiencing anovulatory infertility due to primary ovarianfailure (e.g., where the woman is incapable of final oocyte maturationor ovulation even under COS regimens). The human female subjects of themethods and uses described herein may include women experiencinganovulatory infertility due to secondary ovarian failure. Human femalesubject(s) and woman (women) are used interchangeably herein.

Women at risk for OHSS may include, but are not limited to, women withone or more of PCOS, serum AMH greater than 15 pmol/L, total AFC greaterthan 23 via ultrasound, serum estradiol (E2) greater than 3000 pg/mL, orwomen who have experienced one or more previous episodes of OHSS. Insome embodiments, women who are at risk for OHSS have AMH greater than30 pmol/L, and in some embodiments, greater than 40 pmol/L. In someembodiments, women who are at risk for OHSS have a serum estradiol E2greater than 3500 pg/mL. In other embodiments, the serum E2 is greaterthan 4000 pg/mL, or greater than 5000 pg/mL. In still other embodiments,women at risk for OHSS have serum estradiol E2 greater than 6000 pg/mL.Women at risk for OHSS may include, but are not limited to, women under30 years old, women with low (lean) body weight or low BMI, women withrapidly rising E2 levels, women with a large number of follicles, andcombinations of the foregoing.

Controlled ovarian stimulation (COS) and controlled ovarianhyperstimulation (COH) are used interchangeably herein and may refer tomedical treatment to induce the development of multiple ovarianfollicles to obtain multiple oocytes at follicular aspiration. COS maycomprise three basic elements: 1. exogenous gonadotrophins to stimulatemulti-follicular development; 2. cotreatment with eithergonadotropin-releasing hormone (GnRH) agonist or antagonists to suppresspituitary function and prevent premature ovulation; and 3. triggering offinal oocyte maturation prior to oocyte retrieval.

Use of Compound 1, a metabolite thereof, or a pharmaceuticallyacceptable salt of any of the foregoing, as a trigger agent during ARTor for luteal phase support may result in shorter time to pregnancy,particularly relative to hCG-based trigger agents, as there should beless need for segmentation freeze protocols that result in the need formore IVF cycles. “Triggering,” as used herein, may mean induction, viaan LH surge, of the progression from prophase I to a second arrest atmetaphase II, which remains until fertilization. This induction of finalmaturation initiates the mechanisms that eventually result in ovulation,and thereby make the oocytes destined to undergo ovulation unlessartificial oocyte retrieval is performed first. As used herein, the“luteal phase,” is the period between ovulation and either establishmentof pregnancy or onset of menstrual cycle 2 weeks later. The luteal phaseis characterized by the formation of corpus luteum, which is dependenton LH receptor stimulation by either LH or hCG to secrete the steroidhormones estrogen and progesterone. Following implantation, thedeveloping blastocyst secretes hCG to maintain function of the corpusluteum. Interventions in ART, such as administration of GnRH agonists,may lead to reduced LH levels resulting in inadequate production ofprogesterone, luteal phase insufficiency, and possible loss of thepregnancy. “Luteal phase support” assists in counteracting luteal phaseinsufficiency by increasing levels of LH and/or LH receptor stimulation,therefore maintaining corpus luteum function, and/or increasingprogesterone and promoting embryo implantation.

The disclosure also includes methods and uses comprising administrationof Compound 1, a metabolite thereof, or a pharmaceutically acceptablesalt of any of the foregoing, for decreasing the rate of OHSS. Incertain such embodiments, administration of Compound 1, a metabolitethereof, or a pharmaceutically acceptable salt of any of the foregoing,provides comparable or improved pregnancy rates, decreasing the time topregnancy, and inhibiting premature ovulation. The “inhibition ofpremature ovulation” may refer to inhibiting a follicle/oocyte frombeing released (ovulating) prematurely (i.e., earlier than oocytematuration and timing of ovum collection for IVF or other ART regimen)due to the natural LH surge that induces ovulation. Once naturalovulation occurs, exogenous collection of ovum may become difficult, andIVF or other fertilization techniques cannot be performed, so naturalovulation is to be avoided in these circumstances.

As described above, OHSS is a syndrome characterized by ovarianenlargement and an acute fluid shift into the extravascular space.Symptoms may include, but are not limited to, abdominal distention anddiscomfort, hydrothorax, diminished renal perfusion, edema localized tothe ovaries, ovarian diameter >5 cm or >8 cm, free fluid in abdomen,hematocrit >45%, white cell count >15*109/L, ALT or AST >2×ULN, totalprotein >80 g/L, creatinine >110 mol/L, or, in more severe cases,ascites and/or pleural effusion and sequelae thereof, resulting fromincreased vascular permeability. Complications of OHSS may include butare not limited to, hemoconcentration, hypovolemia, and electrolyteimbalances. Mild OHSS may be classified as follows: Grade 1—abdominaldistention and discomfort, mild to moderate abdominal pain, abdominalbloating or increased waist size, tenderness in the area of the ovaries,and sudden weight increase of more than 6.6 pounds (3 kilograms); andGrade 2—Grade 1 disease plus nausea, vomiting, and/or diarrhea, as wellas ovarian enlargement of 5-12 cm. Moderate OHSS may be classified asfollows: Grade 3—features of mild OHSS plus ultrasonographic evidence ofascites and diminished renal perfusion and function. Severe OHSS may beclassified as follows: Grade 4—features of moderate OHSS plus clinicalevidence of ascites and/or hydrothorax, breathing difficulties orshortness of breath, severe abdominal pain, severe nausea and vomiting,blood clots in legs, decreased urination, and a tight or enlargedabdomen; and Grade 5—all of the above plus a change in the blood volume,increased blood viscosity due to hemoconcentration, coagulationabnormalities, and rapid weight gain, such as 33 to 44 pounds (15 to 20kilograms) in five to 10 days. In severe cases, OHSS may cause death.OHSS may result from increased vascular permeability usually caused bythe effects of exogenous hCG. Methods and uses described hereincomprising administration of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, may be used totreat or prevent OHSS or to treat or prevent one or more OHSS symptoms.As used herein, “treating” or “treatment” of a condition, such as aspecified disease or disorder, may include treating one or more symptomsof the condition and/or preventing the occurrence of the condition.Treatment may include ameliorating one or more symptoms (e.g., pain) orpreventing one or more symptoms, such as alleviating or preventingabdominal distention and discomfort associated with OHSS.

In some embodiments of the methods and uses described herein, the womanmay not experience one or more symptoms of OHSS after administration ofthe initial dose of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing.

In some embodiments of the methods and uses described herein, one ormore symptoms of OHSS may be treated after administration of the initialdose of Compound 1, a metabolite thereof, or a pharmaceuticallyacceptable salt of any of the foregoing.

In some embodiments of the methods and uses described herein, afteradministration of the initial dose of Compound 1, a metabolite thereof,or a pharmaceutically acceptable salt of any of the foregoing, the womanmay not experience a worsening of one or more symptoms of OHSS.

In some embodiments of the methods and uses described herein, afteradministration of the initial dose of Compound 1, a metabolite thereof,or a pharmaceutically acceptable salt of any of the foregoing, one ormore symptoms of OHSS may be ameliorated.

In some embodiments of the methods and uses described herein, afteradministration of the initial dose of Compound 1, a metabolite thereof,or a pharmaceutically acceptable salt of any of the foregoing, the womanmay not experience one or more symptoms selected from the groupconsisting of ascites, pleural effusion, and reduced renal perfusion.

In some embodiments of the methods and uses described herein, afteradministration of the initial dose of Compound 1, a metabolite thereof,or a pharmaceutically acceptable salt of any of the foregoing, one ormore symptoms selected from the group consisting of ascites, pleuraleffusion, and reduced renal perfusion may be treated.

In some embodiments of the methods and uses described herein, afteradministration of the initial dose of Compound 1, a metabolite thereof,or a pharmaceutically acceptable salt of any of the foregoing, ovarysize may not increase to greater than 5 cm in diameter. In someembodiments of the methods and uses described herein, afteradministration of the initial dose of Compound 1, a metabolite thereof,or a pharmaceutically acceptable salt of any of the foregoing, ovarysize may not increase to greater than 8 cm in diameter.

The use of hCG causes the ovary to undergo extensive luteinization,where large amounts of estrogens, progesterone, and local cytokines arereleased. VEGF (vascular endothelial growth factor) production fromfollicles under the effect of hCG may increase vascularhyperpermeability underlying OHSS. In the methods and uses describedherein, use of Compound 1, a metabolite thereof, or a pharmaceuticallyacceptable salt of any of the foregoing, may inhibit or reduce VEGF and,thus, reduce vascular permeability associated with OHSS. Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, may have the ability to induce ovulation in COS withoutincreasing hCG or VEGF levels. Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, may also havethe ability to provide luteal phase support without increasing VEGFlevels.

Although GnRH agonists, when used as trigger agents, are associated withlower risk of OHSS, they also result in much lower pregnancy rates. Useof Compound 1, a metabolite thereof, or a pharmaceutically acceptablesalt of any of the foregoing, as a trigger agent may result in higherpregnancy rates compared to GnRH agonist triggers. In some embodiments,use of Compound 1, a metabolite thereof, or a pharmaceuticallyacceptable salt of any of the foregoing, as a trigger agent may resultin higher pregnancy rates compared to hCG triggers. In some embodiments,use of Compound 1, a metabolite thereof, or a pharmaceuticallyacceptable salt of any of the foregoing, as a trigger agent may resultin biochemical pregnancy rates greater than 40%. Biochemical pregnancymay refer to serum hCG >10 mIU/mL 11 days after embryo transfer. In someembodiments, use of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, as a triggeragent may result in clinical pregnancy rates greater than 40%. Clinicalpregnancy may refer to intrauterine gestational sac with heartbeat onultrasound at 6 weeks gestation. In some embodiments, use of Compound 1,a metabolite thereof, or a pharmaceutically acceptable salt of any ofthe foregoing, as a trigger agent may result in live birth rates greaterthan 40%. Compound 1, a metabolite thereof, or a pharmaceuticallyacceptable salt of any of the foregoing, may induce ovulation, withoutexcess VEGF production in follicles, without sustained increases of hCGand overstimulation of the LH receptors, and without excess amounts ofestrogens, progesterone, or local cytokines, thus possibly mitigatingthe risk of OHSS. Oocyte maturation and ovulation induction withCompound 1, a metabolite thereof, or a pharmaceutically acceptable saltof any of the foregoing, as a trigger agent may ultimately result inpregnancy rates comparable or higher than those seen with currentlyavailable trigger agents. Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, may alsomitigate the symptoms of polycystic ovarian syndrome (PCOS), as they maystimulate normalization of ovulation in patients with ovariandysfunction.

In some embodiments, use of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, for lutealphase support during ART may significantly decrease the risk of OHSScompared to conventional therapy (i.e., hCG luteal phase support).Compound 1, a metabolite thereof, or a pharmaceutically acceptable saltof any of the foregoing, may provide luteal phase support, withoutexcess VEGF production in follicles and without excess amounts ofestrogens, progesterone, or local cytokines, thus possibly mitigatingthe risk of OHSS. Use of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, for lutealphase support may also ultimately result in pregnancy rates comparableor higher than those seen with currently available luteal phase supportagents. In some embodiments, use of Compound 1, a metabolite thereof, ora pharmaceutically acceptable salt of any of the foregoing, for lutealphase support may result in biochemical pregnancy rates greater than40%. In some embodiments, use of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, for lutealphase support may result in clinical pregnancy rates greater than 40%.In some embodiments, use of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, for lutealphase support may result in live birth rates greater than 40%.

The present disclosure provides methods and uses for increasingpregnancy rates following inducement of ovulation with Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, instead of hCG or a GnRH agonist trigger agent. In someembodiments, Compound 1, a metabolite thereof, or a pharmaceuticallyacceptable salt of any of the foregoing, is administered to a humanfemale subject as a trigger agent and administration follows the phaseof COS. In some embodiments, Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, mayeffectively promote maturation of follicles and induce ovulation (i)without increasing the total blood concentration level of VEGF or (ii)by increasing the total level of VEGF for less than 24 hours afteradministration. In some embodiments, Compound 1, a metabolite thereof,or a pharmaceutically acceptable salt of any of the foregoing, are usedfor luteal phase support to increase pregnancy rates.

The present disclosure also provides methods and uses for increasingpregnancy rates following inducement of ovulation with a trigger agentcomprising administration of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, for lutealphase support. In some embodiments, administration of Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, follows or occurs at substantially the same time astriggering. In certain such embodiments, Compound 1, a metabolitethereof, or a pharmaceutically acceptable salt of any of the foregoing,may provide luteal phase support (i) without increasing the total bloodconcentration level of VEGF or (ii) by increasing the total level ofVEGF for less than 24 hours after administration.

Progestogens, such as progesterone, may or may not be administered inconnection with methods and uses described herein. In some embodiments,progesterone is not administered with the methods and uses describedherein. Indeed, one possible advantage of administering multiple dosesof Compound 1, a metabolite thereof, or a pharmaceutically acceptablesalt of any of the foregoing, is that progestogen may not be requiredfor luteal phase support. This would greatly simplify ART protocols, asmany require daily administration of a progestogen, such asprogesterone, often by injection. Sometimes, administration of aprogestogen, such as progesterone, is required for 3 months or moreafter egg retrieval. Eliminating or reducing the need for a progestogen,such as progesterone, through administration of Compound 1, a metabolitethereof, or a pharmaceutically acceptable salt of any of the foregoing,would ease the burden imposed by ART and simplify protocols.

The present disclosure further provides methods and uses for reducingthe likelihood of developing OHSS following inducement of ovulation withCompound 1, a metabolite thereof, or a pharmaceutically acceptable saltof any of the foregoing, instead of an hCG-containing trigger regimen.In some embodiments, the method or use follows the phase of COS andentails administering to a human female subject Compound 1, a metabolitethereof, or a pharmaceutically acceptable salt of any of the foregoing,as a trigger agent, that may effectively promote maturation of folliclesand induce ovulation. In some embodiments, use of Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, as a trigger agent (i) does not increase the total bloodconcentration level of VEGF or (ii) increases the total level of VEGFfor less than 24 hours after administration.

The present disclosure further provides for reducing the likelihood ofdeveloping OHSS following inducement of ovulation by using Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, for luteal phase support. In certain such embodiments,administration of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, follows oroccurs at substantially the same time as triggering. In someembodiments, use of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, for lutealphase support (i) does not increase the total blood concentration levelof VEGF or (ii) increases the total level of VEGF for less than 24 hoursafter administration.

The disclosure provides for methods of using Compound 1, a metabolitethereof, or a pharmaceutically acceptable salt of any of the foregoing,to increase the endogenous LH level in a woman in need thereofundergoing ART, wherein at least about 36 hours after the initial doseis administered, the woman's endogenous LH level in blood is elevatedcompared to the woman's endogenous LH level in blood prior toadministration of the initial dose. In some embodiments, at least about24 hours after the initial dose of Compound 1, a metabolite thereof, ora pharmaceutically acceptable salt of any of the foregoing, isadministered, the woman's endogenous LH level in blood is elevatedcompared to the woman's endogenous LH level in blood prior toadministration of the initial dose. In some embodiments, at least about40 hours after the initial dose of Compound 1, a metabolite thereof, ora pharmaceutically acceptable salt of any of the foregoing, isadministered, the woman's endogenous LH level in blood is elevatedcompared to the woman's endogenous LH level in blood prior toadministration of the initial dose. In some embodiments, at least about44 hours after the initial dose of Compound 1, a metabolite thereof, ora pharmaceutically acceptable salt of any of the foregoing, isadministered, the woman's endogenous LH level in blood is elevatedcompared to the woman's endogenous LH level in blood prior toadministration of the initial dose. In some embodiments, at least about48 hours after the initial dose of Compound 1, a metabolite thereof, ora pharmaceutically acceptable salt of any of the foregoing, isadministered, the woman's endogenous LH level in blood is elevatedcompared to the woman's endogenous LH level in blood prior toadministration of the initial dose. In some embodiments, at least about52 hours after the initial dose of Compound 1, a metabolite thereof, ora pharmaceutically acceptable salt of any of the foregoing, isadministered, the woman's endogenous LH level in blood is elevatedcompared to the woman's endogenous LH level in blood prior toadministration of the initial dose.

The disclosure also provides for methods of using Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, to increase the endogenous LH level in a woman in needthereof undergoing ART, wherein the maximum endogenous LH level in bloodoccurs at least about 12 hours after administration of the initial dose.In some embodiments, after administration of an initial dose of Compound1, a metabolite thereof, or a pharmaceutically acceptable salt of any ofthe foregoing, the maximum endogenous LH level in blood occurs betweenabout 12 hours and about 48 hours after administration of the initialdose. In some embodiments, after administration of an initial dose ofCompound 1, a metabolite thereof, or a pharmaceutically acceptable saltof any of the foregoing, the maximum endogenous LH level in blood occursbetween about 12 hours and about 36 hours after administration of theinitial dose. In some embodiments, after administration of an initialdose of Compound 1, a metabolite thereof, or a pharmaceuticallyacceptable salt of any of the foregoing, the maximum endogenous LH levelin blood occurs between about 12 hours and about 24 hours afteradministration of the initial dose. In some embodiments, afteradministration of an initial dose of Compound 1, a metabolite thereof,or a pharmaceutically acceptable salt of any of the foregoing, themaximum endogenous LH level in blood occurs between about 12 hours andabout 18 hours after administration of the initial dose. In someembodiments, after administration of an initial dose of Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, the maximum endogenous LH level in blood occurs between about14 hours after administration of the initial dose. In some embodiments,after administration of an initial dose of Compound 1, a metabolitethereof, or a pharmaceutically acceptable salt of any of the foregoing,the maximum endogenous LH level in blood occurs between about 16 hoursafter administration of the initial dose. In some embodiments, afteradministration of an initial dose of Compound 1, a metabolite thereof,or a pharmaceutically acceptable salt of any of the foregoing, themaximum endogenous LH level in blood occurs between about 18 hours afteradministration of the initial dose. In some embodiments, afteradministration of an initial dose of Compound 1, a metabolite thereof,or a pharmaceutically acceptable salt of any of the foregoing, themaximum endogenous LH level in blood occurs between about 20 hours afteradministration of the initial dose. In some embodiments, afteradministration of an initial dose of Compound 1, a metabolite thereof,or a pharmaceutically acceptable salt of any of the foregoing, themaximum endogenous LH level in blood occurs between about 22 hours afteradministration of the initial dose. In some embodiments, afteradministration of an initial dose of Compound 1, a metabolite thereof,or a pharmaceutically acceptable salt of any of the foregoing, themaximum endogenous LH level in blood occurs between about 24 hours afteradministration of the initial dose. In some embodiments, afteradministration of an initial dose of Compound 1, a metabolite thereof,or a pharmaceutically acceptable salt of any of the foregoing, themaximum endogenous LH level in blood occurs between about 28 hours afteradministration of the initial dose. In some embodiments, afteradministration of an initial dose of Compound 1, a metabolite thereof,or a pharmaceutically acceptable salt of any of the foregoing, themaximum endogenous LH level in blood occurs between about 32 hours afteradministration of the initial dose. In some embodiments, afteradministration of an initial dose of Compound 1, a metabolite thereof,or a pharmaceutically acceptable salt of any of the foregoing, themaximum endogenous LH level in blood occurs between about 36 hours afteradministration of the initial dose.

The disclosure provides for methods and uses of increasing endogenous LHlevel in a woman undergoing ART and in need of luteal phase support,comprising administering to the woman an initial dose of Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, after said woman has received a trigger dose of an oocytematuration agent as part of an ART regimen. An oocyte maturation agent,or trigger agent, may be used to promote the final maturation of oocytesin ART regimens prior to oocyte retrieval (e.g., IVF, ICSI) or prior toovulation as part of treatment of e.g., PCOS, where after ovulation, IUIor intercourse is timed to maximize the chance of conception. Oocytematuration agents may include, for example, Compound 1, a metabolitethereof, or a pharmaceutically acceptable salt of any of the foregoing,hCG, recombinant luteinizing hormone (rLH), or a GnRH agonist. In someembodiments, the GnRH agonist is selected from the group consisting ofleuprorelin acetate, gonadorelin, buserelin, triptorelin, goserelin,nafarelin, histrelin, deslorelin, meterelin, lecirelin, orpharmaceutically acceptable salts of any of the foregoing. In someembodiments, one or more doses of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, may beadministered to the woman in need of luteal phase support either priorto oocyte retrieval, after oocyte retrieval, or both before and afteroocyte retrieval. Likewise, for ART regimens not incorporating retrievalof the oocyte, one or more doses of Compound 1, a metabolite thereof, ora pharmaceutically acceptable salt of any of the foregoing, may beadministered to the woman in need of luteal phase support either priorto ovulation, after ovulation, or both before and after ovulation.

In some embodiments of the methods and uses described herein, a woman'sendogenous LH level in blood is elevated between about 12 hours to about96 hours after administration of the initial dose of Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, compared to the woman's endogenous LH level in blood prior toadministration of the initial dose. In some embodiments of the methodsand uses described herein, a woman's endogenous LH level in blood iselevated between about 12 hours to about 84 hours after administrationof the initial dose of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, compared tothe woman's endogenous LH level in blood prior to administration of theinitial dose. In some embodiments of the methods and uses describedherein, a woman's endogenous LH level in blood is elevated between about12 hours to about 72 hours after administration of the initial dose ofCompound 1, a metabolite thereof, or a pharmaceutically acceptable saltof any of the foregoing, compared to the woman's endogenous LH level inblood prior to administration of the initial dose. In some embodimentsof the methods and uses described herein, a woman's endogenous LH levelin blood is elevated between about 12 hours to about 60 hours afteradministration of the initial dose of Compound 1, a metabolite thereof,or a pharmaceutically acceptable salt of any of the foregoing, comparedto the woman's endogenous LH level in blood prior to administration ofthe initial dose. In some embodiments of the methods and uses describedherein, a woman's endogenous LH level in blood is elevated between about12 hours to about 48 hours after administration of the initial dose ofCompound 1, a metabolite thereof, or a pharmaceutically acceptable saltof any of the foregoing, compared to the woman's endogenous LH level inblood prior to administration of the initial dose. In some embodimentsof the methods and uses described herein, a woman's endogenous LH levelin blood is elevated between about 14 hours to about 84 hours afteradministration of the initial dose of Compound 1, a metabolite thereof,or a pharmaceutically acceptable salt of any of the foregoing, comparedto the woman's endogenous LH level in blood prior to administration ofthe initial dose. In some embodiments of the methods and uses describedherein, a woman's endogenous LH level in blood is elevated between about14 hours to about 72 hours after administration of the initial dose ofCompound 1, a metabolite thereof, or a pharmaceutically acceptable saltof any of the foregoing, compared to the woman's endogenous LH level inblood prior to administration of the initial dose. In some embodimentsof the methods and uses described herein, a woman's endogenous LH levelin blood is elevated between about 14 hours to about 60 hours afteradministration of the initial dose of Compound 1, a metabolite thereof,or a pharmaceutically acceptable salt of any of the foregoing, comparedto the woman's endogenous LH level in blood prior to administration ofthe initial dose. In some embodiments of the methods and uses describedherein, a woman's endogenous LH level in blood is elevated between about14 hours to about 48 hours after administration of the initial dose ofCompound 1, a metabolite thereof, or a pharmaceutically acceptable saltof any of the foregoing, compared to the woman's endogenous LH level inblood prior to administration of the initial dose. In some embodimentsof the methods and uses described herein, a woman's endogenous LH levelin blood is elevated between about 24 hours to about 84 hours afteradministration of the initial dose of Compound 1, a metabolite thereof,or a pharmaceutically acceptable salt of any of the foregoing, comparedto the woman's endogenous LH level in blood prior to administration ofthe initial dose. In some embodiments of the methods and uses describedherein, a woman's endogenous LH level in blood is elevated between about24 hours to about 72 hours after administration of the initial dose ofCompound 1, a metabolite thereof, or a pharmaceutically acceptable saltof any of the foregoing, compared to the woman's endogenous LH level inblood prior to administration of the initial dose. In some embodimentsof the methods and uses described herein, a woman's endogenous LH levelin blood is elevated between about 24 hours to about 60 hours afteradministration of the initial dose of Compound 1, a metabolite thereof,or a pharmaceutically acceptable salt of any of the foregoing, comparedto the woman's endogenous LH level in blood prior to administration ofthe initial dose. In some embodiments of the methods and uses describedherein, a woman's endogenous LH level in blood is elevated between about24 hours to about 48 hours after administration of the initial dose ofCompound 1, a metabolite thereof, or a pharmaceutically acceptable saltof any of the foregoing, compared to the woman's endogenous LH level inblood prior to administration of the initial dose.

In some embodiments of the methods and uses described herein, thewoman's endogenous LH level in blood is elevated for at least about 36hours after administration of the initial dose of Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, compared to the woman's endogenous LH level in blood prior toadministration of the initial dose. In some embodiments of the methodsand uses described herein, the woman's endogenous LH level in blood iselevated for at least about 48 hours after administration of the initialdose of Compound 1, a metabolite thereof, or a pharmaceuticallyacceptable salt of any of the foregoing, compared to the woman'sendogenous LH level in blood prior to administration of the initialdose. One potential advantage of the methods and uses described hereinis the convenience of an LH level increase beyond 36 hours compared tocurrent triggers. If ovulation reliably happens after approximately 48hours from the initial dose of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, the methodsand uses described herein would be beneficial for the logistics ofscheduling ART appointments compared to the current standard of care.Currently, if a trigger is given around 8 pm, then egg collection occurs36 hours later (8 am). If egg collection could reliably occur at ˜48hours, as provided in the current disclosure, patients could be given atrigger and have egg collection during normal business hours. In someembodiments of the methods and uses described herein, the woman'sendogenous LH level in blood is elevated for at least about 48 hoursafter administration of the initial dose of Compound 1, a metabolitethereof, or a pharmaceutically acceptable salt of any of the foregoing,compared to the woman's endogenous LH level in blood prior toadministration of the initial dose. In some embodiments of the methodsand uses described herein, the woman's endogenous LH level in blood iselevated for about 36 hours to about 16 days after administration of theinitial dose of Compound 1, a metabolite thereof, or a pharmaceuticallyacceptable salt of any of the foregoing, compared to the woman'sendogenous LH level in blood prior to administration of the initialdose. In some embodiments of the methods and uses described herein, thewoman's endogenous LH level in blood is elevated for about 36 hours toabout 12 days after administration of the initial dose of Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, compared to the woman's endogenous LH level in blood prior toadministration of the initial dose. In some embodiments of the methodsand uses described herein, the woman's endogenous LH level in blood iselevated for about 36 hours to about 11 days after administration of theinitial dose of Compound 1, a metabolite thereof, or a pharmaceuticallyacceptable salt of any of the foregoing, compared to the woman'sendogenous LH level in blood prior to administration of the initialdose. In some embodiments of the methods and uses described herein, thewoman's endogenous LH level in blood is elevated for about 36 hours toabout 10 days after administration of the initial dose of Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, compared to the woman's endogenous LH level in blood prior toadministration of the initial dose. In some embodiments of the methodsand uses described herein, the woman's endogenous LH level in blood iselevated for about 36 hours to about 9 days after administration of theinitial dose of Compound 1, a metabolite thereof, or a pharmaceuticallyacceptable salt of any of the foregoing, compared to the woman'sendogenous LH level in blood prior to administration of the initialdose. In some embodiments of the methods and uses described herein, thewoman's endogenous LH level in blood is elevated for about 36 hours toabout 8 days after administration of the initial dose of Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, compared to the woman's endogenous LH level in blood prior toadministration of the initial dose. In some embodiments of the methodsand uses described herein, the woman's endogenous LH level in blood iselevated for about 36 hours to about 7 days after administration of theinitial dose of Compound 1, a metabolite thereof, or a pharmaceuticallyacceptable salt of any of the foregoing, compared to the woman'sendogenous LH level in blood prior to administration of the initialdose. In some embodiments of the methods and uses described herein, thewoman's endogenous LH level in blood is elevated for about 36 hours toabout 6 days after administration of the initial dose of Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, compared to the woman's endogenous LH level in blood prior toadministration of the initial dose. In some embodiments of the methodsand uses described herein, the woman's endogenous LH level in blood iselevated for about 36 hours to about 5 days after administration of theinitial dose of Compound 1, a metabolite thereof, or a pharmaceuticallyacceptable salt of any of the foregoing, compared to the woman'sendogenous LH level in blood prior to administration of the initialdose. In some embodiments of the methods and uses described herein, thewoman's endogenous LH level in blood is elevated for about 36 hours toabout 4 days after administration of the initial dose of Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, compared to the woman's endogenous LH level in blood prior toadministration of the initial dose. In some embodiments of the methodsand uses described herein, the woman's endogenous LH level in blood iselevated for about 36 hours to about 3 days after administration of theinitial dose of Compound 1, a metabolite thereof, or a pharmaceuticallyacceptable salt of any of the foregoing, compared to the woman'sendogenous LH level in blood prior to administration of the initialdose. In some embodiments of the methods and uses described herein, thewoman's endogenous LH level in blood is elevated for about 36 hours toabout 2 days after administration of the initial dose of Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, compared to the woman's endogenous LH level in blood prior toadministration of the initial dose.

In some embodiments of the methods and uses described herein, thewoman's endogenous LH level in blood is elevated for about 48 hours toabout 16 days after administration of the initial dose of Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, compared to the woman's endogenous LH level in blood prior toadministration of the initial dose. In some embodiments of the methodsand uses described herein, the woman's endogenous LH level in blood iselevated for about 48 hours to about 12 days after administration of theinitial dose of Compound 1, a metabolite thereof, or a pharmaceuticallyacceptable salt of any of the foregoing, compared to the woman'sendogenous LH level in blood prior to administration of the initialdose. In some embodiments of the methods and uses described herein, thewoman's endogenous LH level in blood is elevated for about 48 hours toabout 11 days after administration of the initial dose of Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, compared to the woman's endogenous LH level in blood prior toadministration of the initial dose. In some embodiments of the methodsand uses described herein, the woman's endogenous LH level in blood iselevated for about 48 hours to about 10 days after administration of theinitial dose of Compound 1, a metabolite thereof, or a pharmaceuticallyacceptable salt of any of the foregoing, compared to the woman'sendogenous LH level in blood prior to administration of the initialdose. In some embodiments of the methods and uses described herein, thewoman's endogenous LH level in blood is elevated for about 48 hours toabout 9 days after administration of the initial dose of Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, compared to the woman's endogenous LH level in blood prior toadministration of the initial dose. In some embodiments of the methodsand uses described herein, the woman's endogenous LH level in blood iselevated for about 48 hours to about 8 days after administration of theinitial dose of Compound 1, a metabolite thereof, or a pharmaceuticallyacceptable salt of any of the foregoing, compared to the woman'sendogenous LH level in blood prior to administration of the initialdose. In some embodiments of the methods and uses described herein, thewoman's endogenous LH level in blood is elevated for about 48 hours toabout 7 days after administration of the initial dose of Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, compared to the woman's endogenous LH level in blood prior toadministration of the initial dose. In some embodiments of the methodsand uses described herein, the woman's endogenous LH level in blood iselevated for about 48 hours to about 6 days after administration of theinitial dose of Compound 1, a metabolite thereof, or a pharmaceuticallyacceptable salt of any of the foregoing, compared to the woman'sendogenous LH level in blood prior to administration of the initialdose. In some embodiments of the methods and uses described herein, thewoman's endogenous LH level in blood is elevated for about 48 hours toabout 5 days after administration of the initial dose of Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, compared to the woman's endogenous LH level in blood prior toadministration of the initial dose. In some embodiments of the methodsand uses described herein, the woman's endogenous LH level in blood iselevated for about 48 hours to about 4 days after administration of theinitial dose of Compound 1, a metabolite thereof, or a pharmaceuticallyacceptable salt of any of the foregoing, compared to the woman'sendogenous LH level in blood prior to administration of the initialdose. In some embodiments of the methods and uses described herein, thewoman's endogenous LH level in blood is elevated for about 48 hours toabout 3 days after administration of the initial dose of Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, compared to the woman's endogenous LH level in blood prior toadministration of the initial dose.

In some embodiments of the methods and uses described herein, thewoman's endogenous LH level in blood is elevated for about 24 hours toabout 16 days after administration of the initial dose of Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, compared to the woman's endogenous LH level in blood prior toadministration of the initial dose. In some embodiments of the methodsand uses described herein, the woman's endogenous LH level in blood iselevated for about 24 hours to about 12 days after administration of theinitial dose of Compound 1, a metabolite thereof, or a pharmaceuticallyacceptable salt of any of the foregoing, compared to the woman'sendogenous LH level in blood prior to administration of the initialdose. In some embodiments of the methods and uses described herein, thewoman's endogenous LH level in blood is elevated for about 24 hours toabout 11 days after administration of the initial dose of Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, compared to the woman's endogenous LH level in blood prior toadministration of the initial dose. In some embodiments of the methodsand uses described herein, the woman's endogenous LH level in blood iselevated for about 24 hours to about 10 days after administration of theinitial dose of Compound 1, a metabolite thereof, or a pharmaceuticallyacceptable salt of any of the foregoing, compared to the woman'sendogenous LH level in blood prior to administration of the initialdose. In some embodiments of the methods and uses described herein, thewoman's endogenous LH level in blood is elevated for about 24 hours toabout 9 days after administration of the initial dose of Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, compared to the woman's endogenous LH level in blood prior toadministration of the initial dose. In some embodiments of the methodsand uses described herein, the woman's endogenous LH level in blood iselevated for about 24 hours to about 8 days after administration of theinitial dose of Compound 1, a metabolite thereof, or a pharmaceuticallyacceptable salt of any of the foregoing, compared to the woman'sendogenous LH level in blood prior to administration of the initialdose. In some embodiments of the methods and uses described herein, thewoman's endogenous LH level in blood is elevated for about 24 hours toabout 7 days after administration of the initial dose of Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, compared to the woman's endogenous LH level in blood prior toadministration of the initial dose. In some embodiments of the methodsand uses described herein, the woman's endogenous LH level in blood iselevated for about 24 hours to about 6 days after administration of theinitial dose of Compound 1, a metabolite thereof, or a pharmaceuticallyacceptable salt of any of the foregoing, compared to the woman'sendogenous LH level in blood prior to administration of the initialdose. In some embodiments of the methods and uses described herein, thewoman's endogenous LH level in blood is elevated for about 24 hours toabout 5 days after administration of the initial dose of Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, compared to the woman's endogenous LH level in blood prior toadministration of the initial dose. In some embodiments of the methodsand uses described herein, the woman's endogenous LH level in blood iselevated for about 24 hours to about 4 days after administration of theinitial dose of Compound 1, a metabolite thereof, or a pharmaceuticallyacceptable salt of any of the foregoing, compared to the woman'sendogenous LH level in blood prior to administration of the initialdose. In some embodiments of the methods and uses described herein, thewoman's endogenous LH level in blood is elevated for about 24 hours toabout 3 days after administration of the initial dose of Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, compared to the woman's endogenous LH level in blood prior toadministration of the initial dose. In some embodiments of the methodsand uses described herein, the woman's endogenous LH level in blood iselevated for about 24 hours to about 2 days after administration of theinitial dose of Compound 1, a metabolite thereof, or a pharmaceuticallyacceptable salt of any of the foregoing, compared to the woman'sendogenous LH level in blood prior to administration of the initialdose.

Compound 1, a metabolite thereof, or a pharmaceutically acceptable saltof any of the foregoing, may be used to promote the maturation of an ovaor ovum, which may then be subsequently retrieved and fertilized by IVFor ICSI and then transplanted in the uterus (ET). Alternatively, the ovaor ovum may be released from the ovaries (induced ovulation) and besubsequently fertilized via sexual intercourse or IUI. For appropriateand successful oocyte retrieval, there must first occur, the maturationof oocytes and the induction of those oocytes at the appropriate time.The COS phase may help to prevent premature ovulation and the use ofCompound 1, a metabolite thereof, or a pharmaceutically acceptable saltof any of the foregoing, as the trigger agent may facilitate thematuration of the oocytes and allow for retrieval, in vitrofertilization, and embryo transfer or induce release of oocytes(ovulation) and allow for fertilization via sexual intercourse or IUI.As such, administration of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, may result inpregnancy rates that are similar or higher than the current rates,shorter time to pregnancy, and reduced risk for the development of OHSS.

The present disclosure provides methods and uses comprisingadministration of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, for promotingoocyte maturation and triggering ovulation in assisted reproductivetechnologies (ART). The methods and uses described herein may permit useof Compound 1, a metabolite thereof, or a pharmaceutically acceptablesalt of any of the foregoing, for promoting oocyte maturation andtriggering ovulation in ART in the absence of administration of anothertriggering agent, such as hCG, exogenous LH, and/or a GnRH agonist. Insome embodiments of the methods and uses described herein, the initialdose of Compound 1, a metabolite thereof, or a pharmaceuticallyacceptable salt of any of the foregoing, promotes oocyte maturation. Insome embodiments of the methods and uses described herein, oocytematuration occurs without the administration of exogenous hCG orexogenous LH. In certain such embodiments, the yield of mature oocytesis at least 50%. In certain such embodiments, the yield of matureoocytes is at least 75%. Oocyte yield may refer to the percentage ofmature (metaphase 2; M2) oocytes collected from the number of follicles14 mm on final ultrasound scan prior to trigger administration. Oocytesmay be independently classified as M2 by presence of the first polarbody and round ooplasm. In some embodiments, administration of a triggercomprising Compound 1, a metabolite thereof, or a pharmaceuticallyacceptable salt of any of the foregoing, yields an increased amount ofmature oocytes compared to hCG triggering.

As used herein, a “mature” oocyte is one that has reached the metaphaseII stage (M2). Oocytes are classified as M2 by the presence of the firstpolar body and round ooplasm. Oocytes resume meiotic maturation inresponse to the midcycle LH surge. This final oocyte maturation may beinduced medically with either hCG or a GnRH agonist. The former bindsthe LH receptor, while the GnRH agonist promotes the release ofendogenous gonadotropin stores from the hypophysis. The resumption ofmeiosis (so called nuclear maturation) occurs 14-18 hours after thebeginning of the LH surge; meiosis I is completed within 35 hours andthe oocytes reach the metaphase II stage (M2). Meanwhile, in response tothe LH surge, the cumulus cells display almost complete expansion by 20hours; then the mature cumulus-oocyte complex detach from the follicularwall before ovulation. While nuclear maturation and cumulus expansionare closely linked, it is unclear if different LH levels are needed toregulate the two processes.

According to the present disclosure, in some embodiments, administrationof Compound 1, a metabolite thereof, or a pharmaceutically acceptablesalt of any of the foregoing, promotes oocyte maturation and induces(triggers) ovulation in the human female subject (i) without increasingthe level of VEGF or (ii) increasing such level for less than 24 hours.

The present disclosure provides for methods and uses for inducingovulation using Compound 1, a metabolite thereof, or a pharmaceuticallyacceptable salt of any of the foregoing. In certain such embodiments,the method or use may have the steps of administering to a human femalesubject an amount of FSH or the like, coupled with a GnRH agonist orantagonist to facilitate the initial COS phase of ART. In someembodiments, the initial COS phase may be followed by the administrationof Compound 1, a metabolite thereof, or a pharmaceutically acceptablesalt of any of the foregoing, as a trigger agent that effectivelypromotes maturation of oocytes and induces ovulation. In someembodiments, administration of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, as a triggeragent that effectively promotes maturation of oocytes and inducesovulation (i) without increasing the total blood concentration level ofVEGF or (ii) by increasing the total level of VEGF for less than 24hours. In some embodiments, during the COS phase, a GnRH antagonist or aGnRH agonist may be administered in an amount and for a period of timesufficient to act to suppress ovulation in a controlled fashion and isgiven in conjunction with FSH or FSH analogs. In some embodiments, theGnRH antagonist is relugolix.

The present disclosure also provides for methods and uses comprisingadministration of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, for inducingovulation in an anovulatory, human female subject suffering fromsecondary ovarian failure. Secondary ovarian failures originate in thehypothalamus and pituitary glands when they fail to hormonally stimulatethe ovaries and subsequent ovarian function. In some embodiments, themethod or use comprises the steps of (1) pretreating the subject withhuman gonadotropins and (2) administering to the subject Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing.

The present disclosure also provides for methods and uses comprisingadministration of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, for providingluteal phase support in an anovulatory, human female subject sufferingfrom primary ovarian failure. Primary ovarian failure is the depletionor dysfunction of ovarian follicles with cessation of menses before age40 years. “Primary ovarian insufficiency” is the preferred term forprimary ovarian failure advocated by the National Institutes of Healthbecause ovarian function is intermittent or unpredictable in many cases.Because 5-10% of women with primary ovarian insufficiency experiencespontaneous conception and delivery, primary ovarian insufficiency canbe distinguished from natural menopause and also may be described asdecreased ovarian reserve. In some embodiments, the methods and uses mayfurther comprise an ET process.

The present disclosure provides for methods and uses comprisingadministration of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, for inducingfinal follicular maturation and early luteinization in a womanundergoing ART, wherein said woman has undergone pituitarydesensitization and has been pretreated with follicle stimulatinghormones. In certain such embodiments, after the initial dose ofCompound 1, a metabolite thereof, or a pharmaceutically acceptable saltof any of the foregoing, is administered, the woman's endogenous LHlevel in blood is elevated compared to the woman's endogenous LH levelin blood prior to administration of the initial dose. In someembodiments of the methods and uses described herein whereinadministration of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, is forinducing final follicular maturation and early luteinization in a womanundergoing ART, and said woman has undergone pituitary desensitizationand has been pretreated with follicle stimulating hormones, the woman isat risk for OHSS. In some embodiments of the methods and uses describedherein wherein administration of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, is forinducing final follicular maturation and early luteinization in a womanundergoing ART, and said woman has undergone pituitary desensitizationand has been pretreated with follicle stimulating hormones, at leastabout 36 hours after administration, the woman's endogenous LH level inblood is elevated compared to the woman's endogenous LH level in bloodprior to administration of the initial dose. In some embodiments of themethods and uses described herein wherein administration of Compound 1,a metabolite thereof, or a pharmaceutically acceptable salt of any ofthe foregoing, is for inducing final follicular maturation and earlyluteinization in a woman undergoing ART, and said woman has undergonepituitary desensitization and has been pretreated with folliclestimulating hormones, the maximum endogenous LH level in blood occurs atleast about 12 hours after administration of an initial dose of Compound1, a metabolite thereof, or a pharmaceutically acceptable salt of any ofthe foregoing. In some embodiments of the methods and uses describedherein wherein administration of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, is forinducing final follicular maturation and early luteinization in a womanundergoing ART, and said woman has undergone pituitary desensitizationand has been pretreated with follicle stimulating hormones, the maximumendogenous LH level in blood occurs between about 12 hours and about 48hours after administration of an initial dose of Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing. In some embodiments of the methods and uses described hereinwherein administration of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, is forinducing final follicular maturation and early luteinization in a womanundergoing ART, and said woman has undergone pituitary desensitizationand has been pretreated with follicle stimulating hormones, the woman'sendogenous LH level in blood is elevated between about 12 hours to about96 hours after administration of an initial dose of Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, compared to the woman's endogenous LH level in blood prior toadministration of the initial dose. In some embodiments of the methodsand uses described herein wherein administration of Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, is for inducing final follicular maturation and earlyluteinization in a woman undergoing ART, and said woman has undergonepituitary desensitization and has been pretreated with folliclestimulating hormones, the woman's endogenous LH level in blood iselevated for at least about 36 hours after administration compared tothe woman's endogenous LH level in blood prior to administration of theinitial dose. In some embodiments of the methods and uses describedherein wherein administration of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, is forinducing final follicular maturation and early luteinization in a womanundergoing ART, and said woman has undergone pituitary desensitizationand has been pretreated with follicle stimulating hormones, the woman'sendogenous LH level in blood is elevated for at least about 24 hoursafter administration of the initial dose of Compound 1, a metabolitethereof, or a pharmaceutically acceptable salt of any of the foregoing,compared to the woman's endogenous LH level in blood prior toadministration of the initial dose. In some embodiments of the methodsand uses described herein wherein administration of Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, is for inducing final follicular maturation and earlyluteinization in a woman undergoing ART, and said woman has undergonepituitary desensitization and has been pretreated with folliclestimulating hormones, the endogenous LH level in blood is elevated forabout 36 hours to about 16 days after the initial dose of Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing. In some embodiments of the methods and uses described hereinwherein administration of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, is forinducing final follicular maturation and early luteinization in a womanundergoing ART, and said woman has undergone pituitary desensitizationand has been pretreated with follicle stimulating hormones, theendogenous LH level in blood is elevated for about 36 hours to about 12days after the initial dose of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing. In someembodiments of the methods and uses described herein whereinadministration of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, is forinducing final follicular maturation and early luteinization in a womanundergoing ART, and said woman has undergone pituitary desensitizationand has been pretreated with follicle stimulating hormones, theendogenous LH level in blood is elevated for about 24 hours to about 16days after the initial dose of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing. In someembodiments of the methods and uses described herein whereinadministration of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, is forinducing final follicular maturation and early luteinization in a womanundergoing ART, and said woman has undergone pituitary desensitizationand has been pretreated with follicle stimulating hormones, theendogenous LH level in blood is elevated for about 24 hours to about 12days after the initial dose of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing.

The present disclosure provides for methods and uses comprisingadministration of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, for inducingovulation in woman who is anovulatory infertile and the infertility isnot due to primary ovarian failure. In certain such embodiments, afterthe initial dose of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, isadministered, the woman's endogenous LH level in blood is elevatedcompared to the woman's endogenous LH level in blood prior toadministration of the initial dose.

In some embodiments of the methods and uses described herein whereinadministration of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, is forinducing ovulation in woman who is anovulatory infertile and theinfertility is not due to primary ovarian failure, the woman is at riskfor OHSS. In some embodiments of the methods and uses described hereinwherein administration of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, is forinducing ovulation in woman who is anovulatory infertile and theinfertility is not due to primary ovarian failure, at least about 36hours after an initial dose Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, isadministered, the woman's endogenous LH level in blood is elevatedcompared to the woman's endogenous LH level in blood prior toadministration of the initial dose. In some embodiments of the methodsand uses described herein wherein administration of Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, is for inducing ovulation in woman who is anovulatoryinfertile and the infertility is not due to primary ovarian failure, atleast about 24 hours after an initial dose Compound 1, a metabolitethereof, or a pharmaceutically acceptable salt of any of the foregoing,is administered, the woman's endogenous LH level in blood is elevatedcompared to the woman's endogenous LH level in blood prior toadministration of the initial dose. In some embodiments of the methodsand uses described herein wherein administration of Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, is for inducing ovulation in woman who is anovulatoryinfertile and the infertility is not due to primary ovarian failure, themaximum endogenous LH level in blood occurs at least about 12 hoursafter administration of an initial dose of Compound 1, a metabolitethereof, or a pharmaceutically acceptable salt of any of the foregoing.In some embodiments of the methods and uses described herein whereinadministration of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, is forinducing ovulation in woman who is anovulatory infertile and theinfertility is not due to primary ovarian failure, the maximumendogenous LH level in blood occurs between about 12 hours and about 48hours after administration of an initial dose of Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing. In some embodiments of the methods and uses described hereinwherein administration of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, is forinducing ovulation in woman who is anovulatory infertile and theinfertility is not due to primary ovarian failure, the woman'sendogenous LH level in blood is elevated between about 12 hours to about96 hours after administration of an initial dose of Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, compared to the woman's endogenous LH level in blood prior toadministration of the initial dose. In some embodiments of the methodsand uses described herein wherein administration of Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, is for inducing ovulation in woman who is anovulatoryinfertile and the infertility is not due to primary ovarian failure, thewoman's endogenous LH level in blood is elevated for at least about 36hours after administration of the initial dose of Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, compared to the woman's endogenous LH level in blood prior toadministration of the initial dose. In some embodiments of the methodsand uses described herein wherein administration of Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, is for inducing ovulation in woman who is anovulatoryinfertile and the infertility is not due to primary ovarian failure, theendogenous LH level in blood is elevated for at least about 36 hours toabout 16 days after the initial dose of Compound 1, a metabolitethereof, or a pharmaceutically acceptable salt of any of the foregoing.In some embodiments of the methods and uses described herein whereinadministration of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, is forinducing ovulation in woman who is anovulatory infertile and theinfertility is not due to primary ovarian failure, the endogenous LHlevel in blood is elevated for at least about 36 hours to about 12 daysafter the initial dose of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing. In someembodiments of the methods and uses described herein whereinadministration of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, is forinducing ovulation in woman who is anovulatory infertile and theinfertility is not due to primary ovarian failure, the woman'sendogenous LH level in blood is elevated for at least about 24 hoursafter administration of the initial dose of Compound 1, a metabolitethereof, or a pharmaceutically acceptable salt of any of the foregoing,compared to the woman's endogenous LH level in blood prior toadministration of the initial dose. In some embodiments of the methodsand uses described herein wherein administration of Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, is for inducing ovulation in woman who is anovulatoryinfertile and the infertility is not due to primary ovarian failure, theendogenous LH level in blood is elevated for at least about 24 hours toabout 16 days after the initial dose of Compound 1, a metabolitethereof, or a pharmaceutically acceptable salt of any of the foregoing.In some embodiments of the methods and uses described herein whereinadministration of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, is forinducing ovulation in woman who is anovulatory infertile and theinfertility is not due to primary ovarian failure, the endogenous LHlevel in blood is elevated for at least about 24 hours to about 12 daysafter the initial dose of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing.

Larger follicle size at the time of triggering may improve the yield ofmature oocytes. The disclosure provides for administration of doses ofCompound 1, a metabolite thereof, or a pharmaceutically acceptable saltof any of the foregoing, wherein the initial dose is administered whenat least three ovarian follicles of at least about 14 mm are visible viaultrasound. In some embodiments of the methods and uses describedherein, the initial doses of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, areadministered when at least three ovarian follicles of at least about 18mm are visible via ultrasound.

The disclosure also provides for administration of doses of Compound 1,a metabolite thereof, or a pharmaceutically acceptable salt of any ofthe foregoing, wherein the initial dose is administered after ovulation.In some embodiments of the methods and uses described herein, theinitial dose of Compound 1, a metabolite thereof, or a pharmaceuticallyacceptable salt of any of the foregoing, is administered prior toovulation.

In some embodiments, the methods and uses described herein compriseoocyte retrieval. The disclosure provides for administration of doses ofCompound 1, a metabolite thereof, or a pharmaceutically acceptable saltof any of the foregoing, wherein the initial dose is administered afteroocyte retrieval. In some embodiments of the methods and uses describedherein, the initial dose of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, isadministered prior to oocyte retrieval.

In some embodiments of the methods and uses described herein, prior toadministration of the initial dose of Compound 1, a metabolite thereof,or a pharmaceutically acceptable salt of any of the foregoing, a woman'spituitary is desensitized to GnRH prior to administration of the initialdose. In certain embodiments of the methods and uses described herein,the initial dose of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, isadministered when serum estradiol concentration is at least about 0.49nmol/L. In certain embodiments of the methods and uses described herein,the initial dose of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, isadministered when serum estradiol concentration is at least about 0.91nmol/L.

In some embodiments of the methods and uses described herein, an embryois implanted after administration of an initial dose of Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing. In certain such embodiments, implantation occurs within about2 to about 10 days after administration of the initial dose, such asabout 2 days, about 3 days, about 4 days, about 5 days, about 6 days,about 7 days, about 8 days, about 9 days, or about 10 days. In someembodiments of the methods and uses described herein, embryoimplantation occurs within about 1 to about 7 days after oocyteretrieval, such as about 1 day, about 2 days, about 3 days, about 4days, about 5 days, about 6 days, or about 7 days. In certainembodiments of the methods and uses described herein, the embryo isfresh (i.e., the embryo has not been frozen). In certain suchembodiments, the embryo is implanted within the same menstrual cycle asoocyte retrieval. Due to the mode of action of Compound 1, a metabolitethereof, or a pharmaceutically acceptable salt of any of the foregoing,there may be less negative impact on the endometrium compared to currenttreatments. Thus, the endometrium may be ready for implantation (higherendometrial receptivity) immediately after egg retrieval. By not usinghCG-based or GnRH agonist trigger agents (including dual triggers withGnRH agonists), Compound 1, a metabolite thereof, or a pharmaceuticallyacceptable salt of any of the foregoing, may result in less need for asegmentation freezing protocol, thereby reducing the number of IVFcycles; shortening time to pregnancy, while maintaining acceptablepregnancy rates; lowering costs; and reducing reduced side effects, suchas macrosomia (large for gestational age), risk of placenta accreta, andrisk of preeclampsia, with significantly lower OHSS rates. Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, may provide safety and efficacy attributes that represent anadvantage compared to current treatments that require segmentation.

Because fresh embryos may be used in the uses and methods of the presentdisclosure, the disclosure also provides for decreasing the time topregnancy following inducement of ovulation with Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, instead of hCG or a GnRH agonist trigger agent. In someembodiments, Compound 1, a metabolite thereof, or a pharmaceuticallyacceptable salt of any of the foregoing, is administered to a humanfemale subject as a trigger agent and administration follows the phaseof COS. In certain such embodiments, Compound 1, a metabolite thereof,or a pharmaceutically acceptable salt of any of the foregoing, mayeffectively promote maturation of follicles and induce ovulation (i)without increasing the total blood concentration level of VEGF or (ii)by increasing the total level of VEGF for less than 24 hours afteradministration.

The present disclosure also provides methods and uses for decreasing thetime to pregnancy following inducement of ovulation with a trigger agentcomprising administration of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, for lutealphase support. In some embodiments, administration of Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, follows or occurs at substantially the same time astriggering. In certain such embodiments, Compound 1, a metabolitethereof, or a pharmaceutically acceptable salt of any of the foregoing,may provide luteal phase support (i) without increasing the total bloodconcentration level of VEGF or (ii) by increasing the total level ofVEGF for less than 24 hours after administration.

The disclosure provides for methods and uses comprising administrationof doses of Compound 1, a metabolite thereof, or a pharmaceuticallyacceptable salt of any of the foregoing, wherein the method or useinduces ovulation. In certain such embodiments, the human female subjectconceives via intercourse or IUI after administration of at least theinitial dose of Compound 1, a metabolite thereof, or a pharmaceuticallyacceptable salt of any of the foregoing. Administration of Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, to trigger oocyte release without oocyte retrieval may resultin a predictable time of ovulation, with the interval fromadministration to ovulation ranging from 30 to 62 hours afteradministration, or from 36 to 48 hours after administration. This mayallow for sexual intercourse or IUI to conveniently be scheduled atovulation, maximizing the chances of conception. Administration ofCompound 1, a metabolite thereof, or a pharmaceutically acceptable saltof any of the foregoing, may also help women who have trouble ovulatingto ovulate and conceive via intercourse or IUI. In some embodiments,triggering oocyte release using Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, may bereserved for women who require IUI and in whom LH monitoring provesdifficult or unreliable. In some embodiments, triggering oocyte releaseusing Compound 1, a metabolite thereof, or a pharmaceutically acceptablesalt of any of the foregoing, may be used when LH monitoring hasn'tshown an LH surge by cycle day 18 (where cycle day 1 is the first day ofthe preceding menstruation) and there is an ovarian follicle of over 20mm in size.

In some embodiments of the methods and uses described herein, afteradministration of at least the initial dose of Compound 1, a metabolitethereof, or a pharmaceutically acceptable salt of any of the foregoing,the human female subject conceives or gives birth. In some embodiments,the human female subject gives birth via a Caesarean section. In someembodiments, the human female subject gives birth vaginally.

In some embodiments of the methods and uses described herein, the amountor dose, such as the initial dose, of Compound 1, or a correspondingamount of a pharmaceutically acceptable salt thereof, administered orused is about 0.00003 mg to about 0.030 mg. In some embodiments of themethods and uses described herein, the amount or dose, such as theinitial dose, of Compound 1, or a corresponding amount of apharmaceutically acceptable salt thereof, administered or used is about0.001 mg to about 0.030 mg. In some embodiments of the methods and usesdescribed herein, the amount or dose, such as the initial dose, ofCompound 1, or a corresponding amount of a pharmaceutically acceptablesalt thereof, administered or used is about 0.001 mg to about 0.003 mg.In some embodiments of the methods and uses described herein, the amountor dose, such as the initial dose, of Compound 1, or a correspondingamount of a pharmaceutically acceptable salt thereof, administered orused is about 0.00003 mg to about 0.0003 mg. In some embodiments of themethods and uses described herein, the amount or dose, such as theinitial dose, of Compound 1, or a corresponding amount of apharmaceutically acceptable salt thereof, administered or used is about0.00003 mg to about 0.003 mg. In some embodiments of the methods anduses described herein, the amount or dose, such as the initial dose, ofCompound 1, or a corresponding amount of a pharmaceutically acceptablesalt thereof, administered or used is about 0.00003 mg to about 0.00006mg. In some embodiments of the methods and uses described herein, theamount or dose, such as the initial dose, of Compound 1, or acorresponding amount of a pharmaceutically acceptable salt thereof,administered or used is about 0.00003 mg to about 0.00009 mg. In someembodiments of the methods and uses described herein, the amount ordose, such as the initial dose, of Compound 1, or a corresponding amountof a pharmaceutically acceptable salt thereof, administered or used isabout 0.00003 mg to about 0.00015 mg. In some embodiments of the methodsand uses described herein, the amount or dose, such as the initial dose,of Compound 1, or a corresponding amount of a pharmaceuticallyacceptable salt thereof, administered or used is about 0.00003 mg toabout 0.0006 mg. In some embodiments of the methods and uses describedherein, the amount or dose, such as the initial dose, of Compound 1, ora corresponding amount of a pharmaceutically acceptable salt thereof,administered or used is about 0.00003 mg to about 0.0009 mg. In someembodiments of the methods and uses described herein, the amount ordose, such as the initial dose, of Compound 1, or a corresponding amountof a pharmaceutically acceptable salt thereof, administered or used isabout 0.00003 mg to about 0.0015 mg. In some embodiments of the methodsand uses described herein, the amount or dose, such as the initial dose,of Compound 1, or a corresponding amount of a pharmaceuticallyacceptable salt thereof, administered or used is about 0.00003 mg toabout 0.006 mg. In some embodiments of the methods and uses describedherein, the amount or dose, such as the initial dose, of Compound 1, ora corresponding amount of a pharmaceutically acceptable salt thereof,administered or used is about 0.00003 mg to about 0.009 mg. In someembodiments of the methods and uses described herein, the amount ordose, such as the initial dose, of Compound 1, or a corresponding amountof a pharmaceutically acceptable salt thereof, administered or used isabout 0.00003 mg to about 0.015 mg.

In some embodiments of the methods and uses described herein, the amountor dose, such as the initial dose, of Compound 1, or a correspondingamount of a pharmaceutically acceptable salt thereof, administered orused is about 0.0003 mg to about 0.030 mg. In some embodiments of themethods and uses described herein, the amount or dose, such as theinitial dose, of Compound 1, or a corresponding amount of apharmaceutically acceptable salt thereof, administered or used is about0.0003 mg to about 0.0006 mg. In some embodiments of the methods anduses described herein, the amount or dose, such as the initial dose, ofCompound 1, or a corresponding amount of a pharmaceutically acceptablesalt thereof, administered or used is about 0.0003 mg to about 0.0009mg. In some embodiments of the methods and uses described herein, theamount or dose, such as the initial dose, of Compound 1, or acorresponding amount of a pharmaceutically acceptable salt thereof,administered or used is about 0.0003 mg to about 0.0015 mg. In someembodiments of the methods and uses described herein, the amount ordose, such as the initial dose, of Compound 1, or a corresponding amountof a pharmaceutically acceptable salt thereof, administered or used isabout 0.0003 mg to about 0.006 mg. In some embodiments of the methodsand uses described herein, the amount or dose, such as the initial dose,of Compound 1, or a corresponding amount of a pharmaceuticallyacceptable salt thereof, administered or used is about 0.0003 mg toabout 0.009 mg. In some embodiments of the methods and uses describedherein, the amount or dose, such as the initial dose, of Compound 1, ora corresponding amount of a pharmaceutically acceptable salt thereof,administered or used is about 0.0003 mg to about 0.015 mg.

In some embodiments of the methods and uses described herein, the amountor dose, such as the initial dose, of Compound 1, or a correspondingamount of a pharmaceutically acceptable salt thereof, administered orused is about 0.003 mg to about 0.030 mg. In some embodiments of themethods and uses described herein, the amount or dose, such as theinitial dose, of Compound 1, or a corresponding amount of apharmaceutically acceptable salt thereof, administered or used is about0.003 mg to about 0.006 mg. In some embodiments of the methods and usesdescribed herein, the amount or dose, such as the initial dose, ofCompound 1, or a corresponding amount of a pharmaceutically acceptablesalt thereof, administered or used is about 0.003 mg to about 0.009 mg.In some embodiments of the methods and uses described herein, the amountor dose, such as the initial dose, of Compound 1, or a correspondingamount of a pharmaceutically acceptable salt thereof, administered orused is about 0.003 mg to about 0.015 mg.

In some embodiments of the methods and uses described herein, the amountor dose, such as the initial dose, of Compound 1, or a correspondingamount of a pharmaceutically acceptable salt thereof, administered orused is about 0.0003 mg to about 0.003 mg. In some embodiments of themethods and uses described herein, the amount or dose, such as theinitial dose, of Compound 1, or a corresponding amount of apharmaceutically acceptable salt thereof, administered or used is about0.0006 mg to about 0.003 mg. In some embodiments of the methods and usesdescribed herein, the amount or dose, such as the initial dose, ofCompound 1, or a corresponding amount of a pharmaceutically acceptablesalt thereof, administered or used is about 0.0009 mg to about 0.003 mg.In some embodiments of the methods and uses described herein, the amountor dose, such as the initial dose, of Compound 1, or a correspondingamount of a pharmaceutically acceptable salt thereof, administered orused is about 0.0015 mg to about 0.003 mg.

In some embodiments of the methods and uses described herein, the amountor dose, such as the initial dose, of Compound 1, or a correspondingamount of a pharmaceutically acceptable salt thereof, administered orused is about 0.00006 mg to about 0.030 mg. In some embodiments of themethods and uses described herein, the amount or dose, such as theinitial dose, of Compound 1, or a corresponding amount of apharmaceutically acceptable salt thereof, administered or used is about0.00009 mg to about 0.030 mg. In some embodiments of the methods anduses described herein, the amount or dose, such as the initial dose, ofCompound 1, or a corresponding amount of a pharmaceutically acceptablesalt thereof, administered or used is about 0.00015 mg to about 0.030mg. In some embodiments of the methods and uses described herein, theamount or dose, such as the initial dose, of Compound 1, or acorresponding amount of a pharmaceutically acceptable salt thereof,administered or used is about 0.0006 mg to about 0.030 mg. In someembodiments of the methods and uses described herein, the amount ordose, such as the initial dose, of Compound 1, or a corresponding amountof a pharmaceutically acceptable salt thereof, administered or used isabout 0.0009 mg to about 0.030 mg. In some embodiments of the methodsand uses described herein, the amount or dose, such as the initial dose,of Compound 1, or a corresponding amount of a pharmaceuticallyacceptable salt thereof, administered or used is about 0.0015 mg toabout 0.030 mg. In some embodiments of the methods and uses describedherein, the amount or dose, such as the initial dose, of Compound 1, ora corresponding amount of a pharmaceutically acceptable salt thereof,administered or used is about 0.006 mg to about 0.030 mg. In someembodiments of the methods and uses described herein, the amount ordose, such as the initial dose, of Compound 1, or a corresponding amountof a pharmaceutically acceptable salt thereof, administered or used isabout 0.009 mg to about 0.030 mg. In some embodiments of the methods anduses described herein, the amount or dose, such as the initial dose, ofCompound 1, or a corresponding amount of a pharmaceutically acceptablesalt thereof, administered or used is about 0.015 mg to about 0.030 mg.

In some embodiments of the methods and uses described herein, the amountor dose, such as the initial dose, of Compound 1, or a correspondingamount of a pharmaceutically acceptable salt thereof, administered orused is about 0.00003 mg. In some embodiments of the methods and usesdescribed herein, the amount or dose, such as the initial dose, ofCompound 1, or a corresponding amount of a pharmaceutically acceptablesalt thereof, administered or used is about 0.030 mg. In someembodiments of the methods and uses described herein, the amount ordose, such as the initial dose, of Compound 1, or a corresponding amountof a pharmaceutically acceptable salt thereof, administered or used isabout 0.0003 mg. In some embodiments of the methods and uses describedherein, the amount or dose, such as the initial dose, of Compound 1, ora corresponding amount of a pharmaceutically acceptable salt thereof,administered or used is about 0.003 mg. In some embodiments of themethods and uses described herein, the amount or dose, such as theinitial dose, of Compound 1, or a corresponding amount of apharmaceutically acceptable salt thereof, administered or used is about0.00005 mg. In some embodiments of the methods and uses describedherein, the amount or dose, such as the initial dose, of Compound 1, ora corresponding amount of a pharmaceutically acceptable salt thereof,administered or used is about 0.0005 mg. In some embodiments of themethods and uses described herein, the amount or dose, such as theinitial dose, of Compound 1, or a corresponding amount of apharmaceutically acceptable salt thereof, administered or used is about0.005 mg. In some embodiments of the methods and uses described herein,the amount or dose, such as the initial dose, of Compound 1, or acorresponding amount of a pharmaceutically acceptable salt thereof,administered or used is about 0.010 mg. In some embodiments of themethods and uses described herein, the amount or dose, such as theinitial dose, of Compound 1, or a corresponding amount of apharmaceutically acceptable salt thereof, administered or used is about0.0001 mg. In some embodiments of the methods and uses described herein,the amount or dose, such as the initial dose, of Compound 1, or acorresponding amount of a pharmaceutically acceptable salt thereof,administered or used is about 0.001 mg.

Doses of Compound 1, or a corresponding amount of a pharmaceuticallyacceptable salt therefore, may also be expressed as, for example nmol/kg(e.g., as expressed in Example 11) or μg/kg. For example, 0.003 nmol/kgand 0.03 nmol/kg roughly translate to 0.0037 μg/kg and 0.037 μg/kg ofCompound 1 free form, respectively. For a 60 kg woman, the 0.003 nmol/kgdose would be approximately 0.22 μg, or 0.00022 mg, and the 0.03 nmol/kgdose would be 2.2 μg, or 0.0022 mg.

In some embodiments of the methods and uses described herein, the amountor dose of a metabolite of Compound 1, such as Compound 2, or acorresponding amount of a pharmaceutically acceptable salt thereof,administered or used is about 0.00002 mg to about 0.020 mg. In someembodiments of the methods and uses described herein, the amount or doseof a metabolite of Compound 1, such as Compound 2, or a correspondingamount of a pharmaceutically acceptable salt thereof, administered orused is about 0.001 mg to about 5 mg. In some embodiments of the methodsand uses described herein, the amount or dose of a metabolite ofCompound 1, such as Compound 2, or a corresponding amount of apharmaceutically acceptable salt thereof, administered or used is about0.00002 mg to about 0.002 mg. In some embodiments of the methods anduses described herein, the amount or dose of a metabolite of Compound 1,such as Compound 2, or a corresponding amount of a pharmaceuticallyacceptable salt thereof, administered or used is about 0.0002 mg toabout 0.002 mg. In some embodiments of the methods and uses describedherein, the amount or dose of a metabolite of Compound 1, such asCompound 2, or a corresponding amount of a pharmaceutically acceptablesalt thereof, administered or used is about 0.00002 mg to about 5 mg. Insome embodiments of the methods and uses described herein, the amount ordose of a metabolite of Compound 1, such as Compound 2, or acorresponding amount of a pharmaceutically acceptable salt thereof,administered or used is about 0.0002 mg to about 0.020 mg.

Combination Therapies

As briefly described above, Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, may beadministered in combination with other agents employed in ART. Suchagents may include those used in the COS phase (e.g., FSH, hMG, GnRHagonists or antagonists, and combinations thereof); triggering agentssuch as GnRH agonists, hCG, and combinations thereof; and hCG,estradiol, a progestogen, such as progesterone, and combinations thereoffor luteal phase support prior to embryo transfer, IUI, or intercourse.Compound 1, a metabolite thereof, or a pharmaceutically acceptable saltof any of the foregoing, may also be administered in combination witheach other. In some embodiments, multiple sequential doses of Compound1, a metabolite thereof, or a pharmaceutically acceptable salt of any ofthe foregoing, may be administered in the methods and uses describedherein. Therapeutically effective amounts of agents used in combinationmay vary depending on the method of administration, the agent selected,and the condition of the female human subject. As used herein, a“therapeutically effective amount” may refer to an amount of a compoundsufficient to cause a particular effect (e.g., triggering of oocytefinal maturation, support of the endometrium, etc.).

Administration of these agents in combination typically is carried outover a defined time period (usually minutes, hours, days or weeksdepending upon the combination selected). In certain embodiments, agentsare administered in a sequential manner, that is, wherein each agent isadministered at a different time, as well as administration of theseagents, or at least two of the agents, in a substantially simultaneousmanner. Substantially simultaneous administration may be accomplished,for example, by administering to the human female subject a singleinjection having a fixed ratio of each agent or in multiple, singleinjections for each of the agents. Sequential or substantiallysimultaneous administration of each agent may be effected by anyappropriate route including, but not limited to, oral routes,intravenous routes, subcutaneous, intramuscular routes, and directabsorption through mucous membrane tissues. The agents may beadministered by the same route or by different routes. Alternatively,for example, all therapeutic agents may be administered by intravenousinjection. When injected, Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, may becombined with other agents employed in ART in order to reduce the numberof injections given to a patient.

Compound 1, a metabolite thereof, or a pharmaceutically acceptable saltof any of the foregoing, may be used in combination with a number oftherapies included in ART. These therapies, include but are not limitedto, those used in the COS phase of the ART process (e.g., folliclegrowth agents, such as FSH, hMG, and the like that are used to stimulateoocyte development and growth and GnRH agonists or antagonists that areused to control ovarian stimulation and prevent premature ovulation orcombinations of any of the foregoing).

In some embodiments of the methods and uses described herein, FSH isadministered prior to administration of the initial dose of Compound 1,a metabolite thereof, or a pharmaceutically acceptable salt of any ofthe foregoing. In some embodiments of the methods and uses describedherein, FSH is administered about 5 days to about 12 days prior toadministration of the initial dose of Compound 1, a metabolite thereof,or a pharmaceutically acceptable salt of any of the foregoing. Incertain such embodiments, administration of FSH is about 5 days, about 6days, about 7 days, about 8 days, about 9 days, about 10 days, about 11days, or about 12 days prior to administration of the initial dose ofCompound 1, a metabolite thereof, or a pharmaceutically acceptable saltof any of the foregoing.

In some embodiments of the methods and uses described herein, a GnRHantagonist is administered prior to administration of the initial doseof Compound 1, a metabolite thereof, or a pharmaceutically acceptablesalt of any of the foregoing. In some embodiments of the methods anduses described herein, a GnRH antagonist is administered about 2 days toabout 10 days prior to administration of the initial dose of Compound 1,a metabolite thereof, or a pharmaceutically acceptable salt of any ofthe foregoing, such as about 3 days to about 5 days prior toadministration of the initial dose of Compound 1, a metabolite thereof,or a pharmaceutically acceptable salt of any of the foregoing. Incertain such embodiments, administration of the GnRH antagonist is about2 days, about 3 days, about 4 days, about 5 days, about 6 days, about 7days, about 8 days, about 9 days, or about 10 days prior toadministration of the initial dose of Compound 1, a metabolite thereof,or a pharmaceutically acceptable salt of any of the foregoing.

In some embodiments of the methods and uses described herein, a GnRHagonist is administered prior to administration of the initial dose ofCompound 1, a metabolite thereof, or a pharmaceutically acceptable saltof any of the foregoing. In some embodiments of the methods and usesdescribed herein, a GnRH agonist is administered about 14 days to about28 days prior to administration of the initial dose of Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, such as about 14 days to about 17 days prior toadministration of the initial dose of Compound 1, a metabolite thereof,or a pharmaceutically acceptable salt of any of the foregoing. Incertain such embodiments, administration of the GnRH agonist is about 14days, about 15 days, about 16 days, about 17 days, about 18 days, about19 days, about 20 days, about 21 days, about 22 days, about 23 days,about 24 days, about 25 days, about 26 days, about 27 days, or about 28days prior to administration of the initial dose of Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing.

As to the GnRH agonists previously referred to that may be used incombination with Compound 1, a metabolite thereof, or a pharmaceuticallyacceptable salt of any of the foregoing, in ART during the COS phase toprevent premature ovulation, these agents include the following: a GnRH(gonadotropin-releasing hormone) superactive agonist such as leuprorelinacetate, gonadorelin, buserelin, triptorelin, goserelin, nafarelin,histrelin, deslorelin, meterelin, lecirelin, or pharmaceuticallyacceptable salts of any of the foregoing, and the like; or a GnRHantagonist such as cetrorelix, ganirelix, abarelix, nal-blu, antide,azaline B, degarelix, D63153 (ozarelix), OBE2109, teverelix, elagolix,relugolix, or pharmaceutically acceptable salts of any of the foregoing,and the like. In some embodiments during the COS phase to preventpremature ovulation, the GnRH agonist is leuprorelin acetate.

In some embodiments during the COS phase to prevent premature ovulation,the GnRH antagonist may be relugolix, or a pharmaceutically acceptablesalt thereof. Relugolix isN-(4-(1-(2,6-difluorobenzyl)-5-((dimethylamino)methyl)-3-(6-methoxy-3-pyridazinyl)-2,4-dioxo-1,2,3,4-tetrahydrothieno[2,3-d]pyrimidin-6-yl)phenyl)-N′-methoxyureaand is represented by the formula:

Relugolix is orally active and antagonizes GnRH through the GnRHreceptors that are present in the pituitary anterior lobe basophiles(secretory cells), and inhibits the GnRH-stimulated secretion of LH andFSH from these cells. In some embodiments of the methods and usesdescribed herein, the dose of relugolix, or a corresponding amount of apharmaceutically acceptable salt thereof, is about 20 mg to about 120mg, such as 80 mg. In some embodiments of the methods and uses describedherein, the dose of relugolix, or a corresponding amount of apharmaceutically acceptable salt thereof, is less than about 20 mg, lessthan about 40 mg, less than about 80 mg, or less than about 120 mg.

Relugolix, or a pharmaceutically acceptable salt thereof, is anorally-available GnRH antagonist that may be useful in the COS phase ofART when used with FSH or FSH/hMG, to prevent premature ovulation bysuppressing the naturally-occurring LH surge. This then may allow theuse of Compound 1, a metabolite thereof, or a pharmaceuticallyacceptable salt of any of the foregoing, as a trigger to promote oocytematuration for subsequent retrieval, fertilization (in vitro), ET, ICSI,oocyte donation and banking, intercourse or IUI, or ovulation induction.

Relugolix, when used in combination with Compound 1, a metabolitethereof, or a pharmaceutically acceptable salt of any of the foregoing(as the trigger agent), may lower rates of OHSS, increase pregnancyrates, and shorten time to pregnancy compared to when GnRH agonists areadministered instead of relugolix. Additionally, in some embodiments, aformulation for injection comprising Compound 1, a metabolite thereof,or a pharmaceutically acceptable salt of any of the foregoing, may beused with oral FSH and an oral GnRH antagonist, such as relugolix,possibly making the ART cycle predominantly oral versus the currentprotocol comprising many injections.

Compound 1, a metabolite thereof, or a pharmaceutically acceptable saltof any of the foregoing, may also be used with other triggering agentsfor oocyte maturation (i.e., oocyte maturation agents). In someembodiments of the methods and uses described herein, the initial doseof Compound 1, a metabolite thereof, or a pharmaceutically acceptablesalt of any of the foregoing, may be administered after administrationof a GnRH agonist as an oocyte maturation agent. In some embodiments ofthe methods and uses described herein, the initial dose of Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, may be administered at the same time as administration of aGnRH agonist as an oocyte maturation agent. In some embodiments of themethods and uses described herein, the initial dose of Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, may be administered before administration of a GnRH agonistas an oocyte maturation agent. In some embodiments, the GnRH agonist isselected from the group consisting of leuprorelin acetate, gonadorelin,buserelin, triptorelin, goserelin, nafarelin, histrelin, deslorelin,meterelin, lecirelin, or pharmaceutically acceptable salts of any of theforegoing. In some embodiments, oocyte maturation occurs afteradministration of a GnRH agonist. In certain such embodiments, the yieldof mature oocytes is at least 50%. In certain such embodiments, theyield of mature oocytes is at least 75%. As noted above, oocyte yieldmay refer to the percentage of mature oocytes collected from the numberof follicles 14 mm on final ultrasound scan prior to triggeradministration. The disclosure provides that when Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, is administered in combination with a GnRH agonist as anoocyte maturation agent, the human female subject may not experience aworsening of one or more symptoms of OHSS. The disclosure also providesthat when Compound 1, a metabolite thereof, or a pharmaceuticallyacceptable salt of any of the foregoing, is administered in combinationwith a GnRH agonist as an oocyte maturation agent, one or more symptomsof OHSS may be treated.

Compound 1, a metabolite thereof, or a pharmaceutically acceptable saltof any of the foregoing, may be used with hCG as an oocyte maturationagent. In some embodiments, hCG is administered at the same time asadministration of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing. In someembodiments, hCG is administered before administration of Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing. In some embodiments, hCG is administered after administrationof Compound 1, a metabolite thereof, or a pharmaceutically acceptablesalt of any of the foregoing. In some embodiments, hCG is administeredwithin 24 hours of administration of Compound 1, a metabolite thereof,or a pharmaceutically acceptable salt of any of the foregoing. In someembodiments, hCG is administered within 48 hours of administration ofCompound 1, a metabolite thereof, or a pharmaceutically acceptable saltof any of the foregoing. Ovulation will occur between 38 and 40 hoursafter a single hCG injection and trans-vaginal oocyte retrieval istypically performed between 34 and 36 hours after hCG injection, justprior to when the follicles would rupture. In certain embodiments,oocyte maturation occurs after administration of exogenous hCG. Incertain such embodiments, the yield of mature oocytes is at least 50%.In certain such embodiments, the yield of mature oocytes is at least75%. As noted above, oocyte yield may refer to the percentage of matureoocytes collected from the number of follicles 14 mm on final ultrasoundscan prior to trigger administration. The disclosure provides that whenCompound 1, a metabolite thereof, or a pharmaceutically acceptable saltof any of the foregoing, is administered in combination with hCG as anoocyte maturation agent, the human female subject may not experience aworsening of one or more symptoms of OHSS. The disclosure also providesthat when Compound 1, a metabolite thereof, or a pharmaceuticallyacceptable salt of any of the foregoing, is administered in combinationwith hCG as an oocyte maturation agent, one or more symptoms of OHSS maybe treated. In some embodiments, hCG used in ART may be recombinant orurine-derived.

In some embodiments of the methods and uses described herein,recombinant luteinizing hormone (rLH) may be used to achieve oocytematuration. In certain such embodiments, rLH is administered at the sametime as Compound 1, a metabolite thereof, or a pharmaceuticallyacceptable salt of any of the foregoing. In some embodiments, rLH isadministered after Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing. In someembodiments, rLH is administered before Compound 1, a metabolitethereof, or a pharmaceutically acceptable salt of any of the foregoing.

The disclosure provides for use of Compound 1, a metabolite thereof, ora pharmaceutically acceptable salt of any of the foregoing, with both aGnRH agonist and hCG in combination as oocyte maturation agents. In someembodiments, Compound 1, a metabolite thereof, or a pharmaceuticallyacceptable salt of any of the foregoing, is administered at the sametime as the GnRH agonist and hCG. In some embodiments, Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, is administered at before the GnRH agonist and hCG. In someembodiments, Compound 1, a metabolite thereof, or a pharmaceuticallyacceptable salt of any of the foregoing, is administered after the GnRHagonist and hCG.

In some embodiments of the methods and uses described herein, Compound1, or a pharmaceutically acceptable salt thereof, is used in combinationwith a metabolite of Compound 1, such as Compound 2, or apharmaceutically acceptable salt thereof, as oocyte maturation agents.In certain embodiments of the methods and uses described herein,multiple doses of Compound 1, or a pharmaceutically acceptable saltthereof, for example, two doses, are used for oocyte maturation. Incertain embodiments of the methods and uses described herein, multipledoses of a metabolite of Compound 1, such as Compound 2, or apharmaceutically acceptable salt thereof, for example, two doses, areused for oocyte maturation.

In addition, Compound 1, a metabolite thereof, or a pharmaceuticallyacceptable salt of any of the foregoing, may be used in an ET process,with intercourse or IUI, or in ovulation induction in combination with apromoter for implantation or pregnancy such as luteal phase support withestradiol, a progestogen, such as progesterone, low dose hCG, orcombinations thereof. In some embodiments of the methods and usesdescribed herein, a combination of estradiol and a progestogen, such asprogesterone, are administered for luteal phase support. In someembodiments of the methods and uses described herein, a progestogen,such as progesterone, is administered in combination with Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, for luteal phase support. In some embodiments of the methodsand uses described herein, estradiol is administered in combination withCompound 1, a metabolite thereof, or a pharmaceutically acceptable saltof any of the foregoing, for luteal phase support. In some embodimentsof the methods and uses described herein, estradiol and a progestogen,such as progesterone, are administered in combination with Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, for luteal phase support. In some embodiments of the methodsand uses described herein, one or more doses of a progestogen, such asprogesterone, are administered for luteal phase support. In certainembodiments, a progestogen, such as progesterone, may be administeredfrom oocyte retrieval until up to 12 weeks after retrieval. In someembodiments, a progestogen, such as progesterone, may be administered atoocyte retrieval. In some embodiments, a progestogen, such asprogesterone, may be administered from oocyte retrieval until one weekafter retrieval. In some embodiments, a progestogen, such asprogesterone, may be administered from oocyte retrieval until two weeksafter retrieval. In some embodiments, a progestogen, such asprogesterone, may be administered from oocyte retrieval until threeweeks after retrieval. In some embodiments, a progestogen, such asprogesterone, may be administered from oocyte retrieval until four weeksafter retrieval. In some embodiments, a progestogen, such asprogesterone, may be administered from oocyte retrieval until five weeksafter retrieval. In some embodiments, a progestogen, such asprogesterone, may be administered from oocyte retrieval until six weeksafter retrieval. In some embodiments, a progestogen, such asprogesterone, may be administered from oocyte retrieval until sevenweeks after retrieval. In some embodiments, a progestogen, such asprogesterone, may be administered from oocyte retrieval until eightweeks after retrieval. In some embodiments, a progestogen, such asprogesterone, may be administered from oocyte retrieval until nine weeksafter retrieval. In some embodiments, a progestogen, such asprogesterone, may be administered from oocyte retrieval until ten weeksafter retrieval. In some embodiments, a progestogen, such asprogesterone, may be administered from oocyte retrieval until elevenweeks after retrieval.

In some embodiments of the methods and uses described herein, aprogestogen, such as progesterone, is administered for luteal supportafter administration of a Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, trigger. Insome embodiments of the methods and uses described herein, estradiol isadministered for luteal support after administration of a Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, trigger. In some embodiments of the methods and usesdescribed herein, a progestogen, such as progesterone, and estradiol areadministered for luteal support after administration of Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, trigger.

For luteal phase support, in some embodiments, the methods and usesdescribed herein provide for use of natural preparations of progesterone(P4), including dydrogesterone, medrogesterone, and progesterone itself.In some embodiments of the methods and uses described herein, P4 may beadministered orally, intramuscularly (IM), or vaginally. An IMprogestogen, such as progesterone, may be prepared in sesame oil,coconut oil, or peanut oil and the dosage is 50 mg once daily. There areseveral vaginal formulations of a progestogen, such as progesterone,including gels, suppositories, and inserts. Prometrium® may be used as avaginal preparation, with a recommended dose of 200 mg insertedvaginally 3 times a day. The vaginal gel Crinone® 8% (ColumbiaLaboratories Inc.; Livingston, N.J.) may be applied once a day andcontains 90 mg of a progestogen, such as progesterone. One-hundredmilligrams of Endometrin® (Ferring Pharmaceuticals Inc.; Suffern, N.Y.)may be administered vaginally 2 or 3 times daily.

In certain embodiments of the methods and uses described herein, lowdose hCG is administered for luteal phase support. In some embodimentsof the methods and uses described herein, low dose hCG is administeredfor luteal phase support after a Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, trigger. Incertain embodiments of the methods and uses described herein, low dosehCG is administered in combination with a progestogen, such asprogesterone, for luteal phase support after a Compound 1, a metabolitethereof, or a pharmaceutically acceptable salt of any of the foregoing,trigger. In certain embodiments of the methods and uses describedherein, low dose hCG is administered in combination with estradiol forluteal phase support after a Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, trigger. Incertain embodiments of the methods and uses described herein, low dosehCG is administered in combination with a progestogen, such asprogesterone, and estradiol for luteal phase support after a Compound 1,a metabolite thereof, or a pharmaceutically acceptable salt of any ofthe foregoing, trigger.

In some embodiments of the methods and uses described herein, low dosehCG is administered in combination with Compound 1, a metabolitethereof, or a pharmaceutically acceptable salt of any of the foregoing,for luteal phase support. In certain embodiments of the methods and usesdescribed herein, low dose hCG is administered in combination withCompound 1, a metabolite thereof, or a pharmaceutically acceptable saltof any of the foregoing, and a progestogen, such as progesterone, forluteal phase support. In certain embodiments of the methods and usesdescribed herein, low dose hCG is administered in combination withCompound 1, a metabolite thereof, or a pharmaceutically acceptable saltof any of the foregoing, and estradiol for luteal phase support. Incertain embodiments of the methods and uses described herein, low dosehCG is administered in combination with Compound 1, a metabolitethereof, or a pharmaceutically acceptable salt of any of the foregoing,a progestogen, such as progesterone, and estradiol for luteal phasesupport.

In some embodiments, Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, isadministered for luteal support after a woman receives an hCG trigger.In some embodiments, Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, isadministered for luteal support after a woman receives a GnRH agonisttrigger. In some embodiments, Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, isadministered for luteal support after a woman receives both hCG and aGnRH agonist trigger. In some embodiments, Compound 1, a metabolitethereof, or a pharmaceutically acceptable salt of any of the foregoing,is administered for luteal support after a woman receives a Compound 1,a metabolite thereof, or a pharmaceutically acceptable salt of any ofthe foregoing, trigger. In some embodiments, Compound 1, a metabolitethereof, or a pharmaceutically acceptable salt of any of the foregoing,is administered for luteal support after a woman receives both a GnRHagonist trigger and a Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, trigger. Insome embodiments, Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, isadministered for luteal support after a woman receives both an hCGtrigger and a Compound 1, a metabolite thereof, or a pharmaceuticallyacceptable salt of any of the foregoing, trigger. In some embodiments,Compound 1, a metabolite thereof, or a pharmaceutically acceptable saltof any of the foregoing, is administered for luteal support after awoman receives an hCG trigger, a GnRH agonist trigger, and a Compound 1,a metabolite thereof, or a pharmaceutically acceptable salt of any ofthe foregoing, trigger.

In some embodiments of the methods and uses described herein, Compound1, or a pharmaceutically acceptable salt thereof, is used in combinationwith a metabolite of Compound 1, such as Compound 2, or apharmaceutically acceptable salt thereof, for luteal phase support. Incertain embodiments of the methods and uses described herein, multipledoses of Compound 1, or a pharmaceutically acceptable salt thereof, forexample, two doses, are used for luteal phase support. In certainembodiments of the methods and uses described herein, multiple doses ofa metabolite of Compound 1, such as Compound 2, or a pharmaceuticallyacceptable salt thereof, for example, two doses, are used for lutealphase support.

An advantage of Compound 1, or a pharmaceutically acceptable saltthereof, is that it may be used not only as a trigger for ovulation, butmay be re-administered one or more times to provide additional LH forluteal phase support. This may reduce the need for progesteroneinjections and supplementation. Current ART protocols typically use aGnRH agonist trigger followed by low dose hCG for luteal phase support,but this increases the risk of OHSS. Administration of one or more dosesof Compound 1, or a pharmaceutically acceptable salt thereof, may reducethe risk of OHSS present in current ART protocols and act as a triggerfor oocyte maturation and/or as luteal phase support. Multiple doses ofCompound 1, or a pharmaceutically acceptable salt thereof, may reducethe risk of OHSS by preventing an increase in serum VEGF, thus, reducingvascular permeability.

In some embodiments, Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, isadministered in combination with a protease inhibitor. In certain suchembodiments, administration of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, in combinationwith a protease inhibitor is for luteal phase support. In certain suchembodiments, the formulation administered comprises both Compound 1, ametabolite thereof, or a pharmaceutically acceptable salt of any of theforegoing, and a protease inhibitor. In some embodiments, theformulation comprising both Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, and a proteaseinhibitor is immediate release, extended or sustained release, ordelayed release. In certain such embodiments, the formulation mayexhibit an immediate release profile. In some embodiments, theformulation comprising both Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, and a proteaseinhibitor may exhibit an extended or sustained release profile. In someembodiments, the formulation comprising both Compound 1, a metabolitethereof, or a pharmaceutically acceptable salt of any of the foregoing,and a protease inhibitor may exhibit a delayed release profile. In someembodiments, the formulation comprising Compound 1, a metabolitethereof, or a pharmaceutically acceptable salt of any of the foregoing,is administered separately than the formulation comprising a proteaseinhibitor. Possible protease inhibitors that may be used in the methodsand uses of the disclosure include, but are not limited to,4-(2-aminoethyl) benzenesulfonyl fluoride hydrochloride (AEBSF), EDTA,bestatin, E-64, leupeptin, such as leupeptin hemisulfate monohydrate,aprotinin, (2S,3S)-3-carboxyoxirane-2-carbonyl]-L-leucine(4-guanidinobutyl)amide hemihydrate, and salts of any of the foregoing.

Formulations, Dosing, and Administration

The disclosure provides formulations or pharmaceutical compositionscomprising Compound 1, a metabolite thereof, or a pharmaceuticallyacceptable salt of any of the foregoing, and a pharmaceuticallyacceptable excipient or carrier for use in the methods and usesdisclosed herein. In ART, Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, may beadministered as a formulation or pharmaceutical composition with one ormore pharmaceutically acceptable carriers or excipients. The amount ofCompound 1, a metabolite thereof, or a pharmaceutically acceptable saltof any of the foregoing, administered may vary according to the weight,age, and medical condition of the human female subject. Therapeuticallyeffective amounts of Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, used hereinmay vary depending on the method of administration, the agent selected,and the condition of the female human subject.

Compound 1, or a pharmaceutically acceptable salt thereof, is stable andmay be stored at 4° C. versus many peptide drugs which must be storedand reconstituted at −20° C.

Formulations of the disclosure may be formulated for differing rates ofrelease, such as immediate release, extended or sustained release, ordelayed release. In some embodiments, the formulations may exhibit animmediate release profile. In some embodiments, the formulations mayexhibit an extended or sustained release profile. In some embodiments,the formulations may exhibit a delayed release profile.

The carrier or excipients of the formulations of the disclosure may be ablend of excipients, and amounts, which may optimize the efficacy of theformulation. Excipients include, for example, various organic orinorganic excipients or carrier substances.

Formulations comprising Compound 1, a metabolite thereof, or apharmaceutically acceptable salt of any of the foregoing, may beadministered via injection, e.g., intravenously (IV), intramuscularly(IM) or subcutaneously (SC). In some embodiments, the injection is IM.In other embodiments, the injection is SC. In some embodiments, the SCinjection is a bolus. In some embodiments, the SC injection is aninfusion. Injection typically entails delivery of a discrete amount of aliquid composition with a hypodermic needle and a syringe or otherinjection devices known in the art. Examples of injection may alsoinclude infusion and intravenous devices. Injection may take placeimmediately or over a period of time.

An injectable dosage formulation comprising Compound 1, a metabolitethereof, or a pharmaceutically acceptable salt of any of the foregoing,may be based on water or oil as a vehicle or carrier. Examples ofvehicles or carriers include, but are not limited to, water forinjection, alcohol, propylene glycol, macrogol, sesame oil, corn oil,olive oil, vegetable oil, cottonseed oil, corn oil, etc. In someembodiments, the vehicle or carrier is water for injection. Alternately,the injectable dosage formulation may take the form of an emulsion,suspension, or solution. The injectable dosage formulation may haveother ingredients, such as dispersing agents, dissolution aids,suspending agents, stabilizers, surfactants, solubilizing agents,surfactants, buffering agents, isotonizing agents, pH adjusting agents,and soothing agents. Suitable dispersing agents include, but are notlimited to, Tween 80® (Atlas Powder Company USA), HCO 60™ (NikkoChemicals Co., Ltd.), polyethylene glycol, carboxymethyl cellulose,sodium alginate, hydroxypropylmethyl cellulose, dextrose, and dextrin.In some embodiments, the dispersing agent is dextrose. Suitablestabilizers include, but are not limited to, ascorbic acid and sodiumpyrosulfite. Suitable surfactants include, but are not limited to,polysorbate 80 and macrogol. Suitable solubilizing agents include, butare not limited to, glycerin and ethanol. Suitable buffering agentsinclude, but are not limited to, phosphoric acid or its alkali metalsalts, citric acid or its alkali metal salts, acetates, and carbonates.Suitable isotonizing agents include, but are not limited to, sodiumchloride, glycerine, potassium chloride, mannitol, sorbitol, glycerol,and glucose. In some embodiments, the isotonizing agent is mannitol.Suitable pH adjusting agents include, but are not limited to,hydrochloric acid, acetic acid, and sodium hydroxide. In someembodiments, the pH adjusting agent is acetic acid. Suitablepreservatives include, but are not limited to, ethyl p-oxybenzoate,benzoic acid, methylparabene, propylparabene, and benzyl alcohol.Suitable solubilizers include, but are not limited to, concentratedglycerin and meglumine. Suitable dissolution aids include, but are notlimited to, propylene glycol and saccharose. Suitable soothing agentsinclude, but are not limited to, glucose and benzyl alcohol. Examples ofdissolution aids include polyethylene glycol, propylene glycol,D-mannitol, benzyl benzoate, ethanol, trisaminomethane, cholesterol,triethanolamine, sodium carbonate, sodium citrate, etc. Examples ofsuspending agents include surfactants such as stearyl triethanolamine,sodium laurylsulfate, lauryl aminopropionate, lecithin, benzalkoniumchloride, benzethonium chloride, glycerine monostearate, etc.;hydrophilic polymers such as polyvinyl alcohol, polyvinyl pyrrolidone,sodium carboxymethylcellulose, methylcellulose, hydroxymethylcellulose,hydroxyethylcellulose, hydroxypropylcellulose, etc. Other excipientsthat may be used include, for example, lactose, sucrose, starch,cornstarch, crystalline cellulose, silicic anhydride, light anhydroussilicic acid, and the like.

Other additives, such as preservatives, antioxidants, and coloringagents, may also be used. Possible preservatives include, but are notlimited to, paraoxybenzoic acid ester, chlorobutanol, benzyl alcohol,phenethyl alcohol, dehydroacetic acid, sorbic acid, and the like.Possible antioxidants include, but are not limited to, sulfite, ascorbicacid, and the like. Possible coloring agents include, but are notlimited to, ferric oxides.

In some embodiments, the injectable formulation of the disclosurecomprises Compound 1, a metabolite thereof, or a pharmaceuticallyacceptable salt of any of the foregoing, mannitol, acetic acid, andwater for injection. In certain such embodiments, the formulationfurther comprises glucose and/or dextrose.

In some embodiments, the injectable formulation of the disclosure may beadjusted to pH of 2 to 12, preferably 2.5 to 8.0 by adding a pHadjusting-agent.

The amount administered in the injectable dosage formulation may beeffective to promote egg maturation in ART, such as IVF, ICSI, oocytedonation and banking, regulation of a menstrual cycle so a human femalesubject may conceive via intercourse or IUI, ovulation induction, and/oran ET process. In some embodiments, injectable formulations of thedisclosure may be administered as a single dose. In some embodiments,injections may be carried out when release and retrieval of matureoocytes is desired, such as during the trigger phase, prior to oocyteretrieval from the ovaries, IVF, ICSI, oocyte donation and banking,regulation of a menstrual cycle so a human female subject may conceivevia intercourse or IUI, and implantation of fertilized embryo into theuterus. In some embodiments, injectable formulations of the disclosuremay be administered as a single dose. In some embodiments, injectableformulations of the disclosure may be administered as a divided dose. Insome embodiments, two doses of an injectable formulation of thedisclosure may be administered. In some embodiments, the secondinjectable dose is administered within about 8 to about 60 hours afteradministration of the initial dose. In some embodiments, three doses ofan injectable formulation of the disclosure may be administered. In someembodiments, the third injectable dose is administered within about 8 toabout 60 hours after administration of the second dose. In someembodiments, a third injectable dose is administered and is followed byadministration of one to five additional injectable doses. In someembodiments wherein a third injectable dose is administered and isfollowed by administration of one to five additional injectable doses,the administration of the one to five additional doses is within about 8to about 60 hours after the prior dose is administered.

Compound 1, a metabolite thereof, or a pharmaceutically acceptable saltof any of the foregoing, may also be administered in a depotformulation. Injectable depot forms may be made by formingmicroencapsulated matrices of the drug in biodegradable polymers such aspolylactide-polyglycolide, poly(orthoesters), poly(anhydrides), and(poly)glycols, such as PEG. Depending upon the ratio of drug to polymerand the nature of the particular polymer employed, the rate of drugrelease may be controlled. Depot injectable formulations may also beprepared by entrapping the drug in liposomes or microemulsions which arecompatible with body tissues.

The injectable formulations of the disclosure may be sterilized, forexample, by filtration through a bacterial-retaining filter, or byincorporating sterilizing agents in the form of sterile solidcompositions which may be dissolved or dispersed in sterile water orother sterile injectable medium just prior to use.

Compound 1, a metabolite thereof, or a pharmaceutically acceptable saltof any of the foregoing, may also be administered in an intranasalformulation. The formulation may take the form of a liquid so that itmay be sprayed into the nostrils, although a semi-solid formulation,such as an intranasal cream, may be possible. Liquid intranasalformulations may take the form of a solution, suspension, or emulsionand may be aqueous or non-aqueous. The ingredients listed above for theinjectable dosage form may also be employed according to methods knownin the art to prepare an intranasal formulation.

The amount of Compound 1, a metabolite thereof, or a pharmaceuticallyacceptable salt of any of the foregoing, administered intranasally maybe effective to promote egg maturation in ART, such as IVF, ICSI, oocytedonation and banking, regulation of a menstrual cycle so a human femalesubject may conceive via intercourse or IUI, ovulation induction, and/oran ET process. In some embodiments, intranasal formulations of thedisclosure may be administered in a single dose. In some embodiments,intranasal administration may be carried out when release and retrievalof mature oocytes is desired, such as during the trigger phase, prior tooocyte retrieval from the ovaries, IVF, ICSI, oocyte donation andbanking, regulation of a menstrual cycle so a human female subject mayconceive via intercourse or IUI, and implantation of fertilized embryointo the uterus. In some embodiments, the intranasal formulations of thedisclosure may be administered in a single dose. In some embodiments,the intranasal formulations of the disclosure may be administered in adivided dose. In some embodiments, two doses of an intranasalformulation of the disclosure may be administered. In some embodiments,the second intranasal dose is administered within about 8 to about 60hours after administration of the initial dose. In some embodiments,three doses of an intranasal formulation of the disclosure may beadministered. In some embodiments, the third intranasal dose isadministered within about 8 to about 60 hours after administration ofthe second dose. In some embodiments, a third intranasal dose isadministered and is followed by administration of one to five additionalintranasal doses. In some embodiments wherein a third intranasal dose isadministered and is followed by administration of one to five additionalintranasal doses, the administration of the one to five additional dosesis within about 8 to about 60 hours after the prior dose isadministered.

In addition, conventional additives such as a preservative, anantioxidant, a colorant, a sweetener, an adsorbent, a wetting agent,etc. may be appropriately used in suitable amounts, in all dosage formsif necessary. Possible preservatives include, for example,p-hydroxybenzoates, paraoxybenzoic acid ester, chlorobutanol, benzylalcohol, phenethyl alcohol, dehydroacetic acid, sorbic acid, ethylp-oxybenzoate, benzoic acid, methylparabene, propylparabene, and thelike. Possible antioxidants include, for example, sulfite, ascorbicacid, α-tocopherol, and the like.

Dosage forms containing Compound 1, and pharmaceutically acceptablesalts thereof, are disclosed, for example, in U.S. Patent ApplicationPublication Nos. 2012/0302508, 2013/0210742, 2011/0312898, and2011/0212890, the disclosures of which are herein incorporated byreference. The publications also disclose various indications and enduses for Compound 1.

In some embodiments, formulations or pharmaceutical compositions of thedisclosure comprise about 0.00003 mg to about 0.030 mg of Compound 1, ora corresponding amount of a pharmaceutically acceptable salt thereof. Insome embodiments, formulations or pharmaceutical compositions of thedisclosure comprise about 0.001 mg to about 0.030 mg of Compound 1, or acorresponding amount of a pharmaceutically acceptable salt thereof. Insome embodiments, formulations or pharmaceutical compositions of thedisclosure comprise about 0.001 mg to about 0.003 mg of Compound 1, or acorresponding amount of a pharmaceutically acceptable salt thereof. Insome embodiments, formulations or pharmaceutical compositions of thedisclosure comprise about 0.00003 mg to about 0.0003 mg of Compound 1,or a corresponding amount of a pharmaceutically acceptable salt thereof.In some embodiments, formulations or pharmaceutical compositions of thedisclosure comprise about 0.00003 mg to about 0.003 mg of Compound 1, ora corresponding amount of a pharmaceutically acceptable salt thereof. Insome embodiments, formulations or pharmaceutical compositions of thedisclosure comprise about 0.00003 mg to about 0.00006 mg of Compound 1,or a corresponding amount of a pharmaceutically acceptable salt thereof.In some embodiments, formulations or pharmaceutical compositions of thedisclosure comprise about 0.00003 mg to about 0.00009 mg of Compound 1,or a corresponding amount of a pharmaceutically acceptable salt thereof.In some embodiments, formulations or pharmaceutical compositions of thedisclosure comprise about 0.00003 mg to about 0.00015 mg of Compound 1,or a corresponding amount of a pharmaceutically acceptable salt thereof.In some embodiments, formulations or pharmaceutical compositions of thedisclosure comprise about 0.00003 mg to about 0.0006 mg of Compound 1,or a corresponding amount of a pharmaceutically acceptable salt thereof.In some embodiments, formulations or pharmaceutical compositions of thedisclosure comprise about 0.00003 mg to about 0.0009 mg of Compound 1,or a corresponding amount of a pharmaceutically acceptable salt thereof.In some embodiments, formulations or pharmaceutical compositions of thedisclosure comprise about 0.00003 mg to about 0.0015 mg of Compound 1,or a corresponding amount of a pharmaceutically acceptable salt thereof.In some embodiments, formulations or pharmaceutical compositions of thedisclosure comprise about 0.00003 mg to about 0.006 mg of Compound 1, ora corresponding amount of a pharmaceutically acceptable salt thereof. Insome embodiments, formulations or pharmaceutical compositions of thedisclosure comprise about 0.00003 mg to about 0.009 mg of Compound 1, ora corresponding amount of a pharmaceutically acceptable salt thereof. Insome embodiments, formulations or pharmaceutical compositions of thedisclosure comprise about 0.00003 mg to about 0.015 mg of Compound 1, ora corresponding amount of a pharmaceutically acceptable salt thereof.

In some embodiments, formulations or pharmaceutical compositions of thedisclosure comprise about 0.0003 mg to about 0.030 mg of Compound 1, ora corresponding amount of a pharmaceutically acceptable salt thereof. Insome embodiments, formulations or pharmaceutical compositions of thedisclosure comprise about 0.0003 mg to about 0.0006 mg of Compound 1, ora corresponding amount of a pharmaceutically acceptable salt thereof. Insome embodiments, formulations or pharmaceutical compositions of thedisclosure comprise about 0.0003 mg to about 0.0009 mg of Compound 1, ora corresponding amount of a pharmaceutically acceptable salt thereof. Insome embodiments, formulations or pharmaceutical compositions of thedisclosure comprise about 0.0003 mg to about 0.0015 mg of Compound 1, ora corresponding amount of a pharmaceutically acceptable salt thereof. Insome embodiments, formulations or pharmaceutical compositions of thedisclosure comprise about 0.0003 mg to about 0.006 mg of Compound 1, ora corresponding amount of a pharmaceutically acceptable salt thereof. Insome embodiments, formulations or pharmaceutical compositions of thedisclosure comprise about 0.0003 mg to about 0.009 mg of Compound 1, ora corresponding amount of a pharmaceutically acceptable salt thereof. Insome embodiments, formulations or pharmaceutical compositions of thedisclosure comprise about 0.0003 mg to about 0.015 mg of Compound 1, ora corresponding amount of a pharmaceutically acceptable salt thereof.

In some embodiments, formulations or pharmaceutical compositions of thedisclosure comprise about 0.003 mg to about 0.030 mg of Compound 1, or acorresponding amount of a pharmaceutically acceptable salt thereof. Insome embodiments, formulations or pharmaceutical compositions of thedisclosure comprise about 0.003 mg to about 0.006 mg of Compound 1, or acorresponding amount of a pharmaceutically acceptable salt thereof. Insome embodiments, formulations or pharmaceutical compositions of thedisclosure comprise about 0.003 mg to about 0.009 mg of Compound 1, or acorresponding amount of a pharmaceutically acceptable salt thereof. Insome embodiments, formulations or pharmaceutical compositions of thedisclosure comprise about 0.003 mg to about 0.015 mg of Compound 1, or acorresponding amount of a pharmaceutically acceptable salt thereof.

In some embodiments, formulations or pharmaceutical compositions of thedisclosure comprise about 0.0003 mg to about 0.003 mg of Compound 1, ora corresponding amount of a pharmaceutically acceptable salt thereof. Insome embodiments, formulations or pharmaceutical compositions of thedisclosure comprise about 0.0006 mg to about 0.003 mg of Compound 1, ora corresponding amount of a pharmaceutically acceptable salt thereof. Insome embodiments, formulations or pharmaceutical compositions of thedisclosure comprise about 0.0009 mg to about 0.003 mg of Compound 1, ora corresponding amount of a pharmaceutically acceptable salt thereof. Insome embodiments, formulations or pharmaceutical compositions of thedisclosure comprise about 0.0015 mg to about 0.003 mg of Compound 1, ora corresponding amount of a pharmaceutically acceptable salt thereof.

In some embodiments, formulations or pharmaceutical compositions of thedisclosure comprise about 0.00006 mg to about 0.030 mg of Compound 1, ora corresponding amount of a pharmaceutically acceptable salt thereof. Insome embodiments, formulations or pharmaceutical compositions of thedisclosure comprise about 0.00009 mg to about 0.030 mg of Compound 1, ora corresponding amount of a pharmaceutically acceptable salt thereof. Insome embodiments, formulations or pharmaceutical compositions of thedisclosure comprise about 0.00015 mg to about 0.030 mg of Compound 1, ora corresponding amount of a pharmaceutically acceptable salt thereof. Insome embodiments, formulations or pharmaceutical compositions of thedisclosure comprise about 0.0006 mg to about 0.030 mg of Compound 1, ora corresponding amount of a pharmaceutically acceptable salt thereof. Insome embodiments, formulations or pharmaceutical compositions of thedisclosure comprise about 0.0009 mg to about 0.030 mg of Compound 1, ora corresponding amount of a pharmaceutically acceptable salt thereof. Insome embodiments, formulations or pharmaceutical compositions of thedisclosure comprise about 0.0015 mg to about 0.030 mg of Compound 1, ora corresponding amount of a pharmaceutically acceptable salt thereof. Insome embodiments, formulations or pharmaceutical compositions of thedisclosure comprise about 0.006 mg to about 0.030 mg of Compound 1, or acorresponding amount of a pharmaceutically acceptable salt thereof. Insome embodiments, formulations or pharmaceutical compositions of thedisclosure comprise about 0.009 mg to about 0.030 mg of Compound 1, or acorresponding amount of a pharmaceutically acceptable salt thereof. Insome embodiments, formulations or pharmaceutical compositions of thedisclosure comprise about 0.015 mg to about 0.030 mg of Compound 1, or acorresponding amount of a pharmaceutically acceptable salt thereof.

In some embodiments, formulations or pharmaceutical compositions of thedisclosure comprise about 0.00003 mg of Compound 1, or a correspondingamount of a pharmaceutically acceptable salt thereof. In someembodiments, formulations or pharmaceutical compositions of thedisclosure comprise about 0.030 mg of Compound 1, or a correspondingamount of a pharmaceutically acceptable salt thereof. In someembodiments, formulations or pharmaceutical compositions of thedisclosure comprise about 0.0003 mg of Compound 1, or a correspondingamount of a pharmaceutically acceptable salt thereof. In someembodiments, formulations or pharmaceutical compositions of thedisclosure comprise about 0.003 mg of Compound 1, or a correspondingamount of a pharmaceutically acceptable salt thereof. In someembodiments, formulations or pharmaceutical compositions of thedisclosure comprise about 0.00005 mg of Compound 1, or a correspondingamount of a pharmaceutically acceptable salt thereof. In someembodiments, formulations or pharmaceutical compositions of thedisclosure comprise about 0.0005 mg of Compound 1, or a correspondingamount of a pharmaceutically acceptable salt thereof. In someembodiments, formulations or pharmaceutical compositions of thedisclosure comprise about 0.005 mg of Compound 1, or a correspondingamount of a pharmaceutically acceptable salt thereof. In someembodiments, formulations or pharmaceutical compositions of thedisclosure comprise about 0.010 mg of Compound 1, or a correspondingamount of a pharmaceutically acceptable salt thereof. In someembodiments, formulations or pharmaceutical compositions of thedisclosure comprise about 0.0001 mg of Compound 1, or a correspondingamount of a pharmaceutically acceptable salt thereof. In someembodiments, formulations or pharmaceutical compositions of thedisclosure comprise about 0.001 mg of Compound 1, or a correspondingamount of a pharmaceutically acceptable salt thereof.

In some embodiments, formulations or pharmaceutical compositions of thedisclosure comprise about 0.00002 mg to about 0.020 mg of a metaboliteof Compound 1, such as Compound 2, or a corresponding amount of apharmaceutically acceptable salt thereof. In some embodiments,formulations or pharmaceutical compositions of the disclosure compriseabout 0.001 mg to about 5 mg of a metabolite of Compound 1, such asCompound 2, or a corresponding amount of a pharmaceutically acceptablesalt thereof. In some embodiments, formulations or pharmaceuticalcompositions of the disclosure comprise about 0.00002 mg to about 0.002mg of a metabolite of Compound 1, such as Compound 2, or a correspondingamount of a pharmaceutically acceptable salt thereof. In someembodiments, formulations or pharmaceutical compositions of thedisclosure comprise about 0.0002 mg to about 0.002 mg of a metabolite ofCompound 1, such as Compound 2, or a corresponding amount of apharmaceutically acceptable salt thereof. In some embodiments,formulations or pharmaceutical compositions of the disclosure compriseabout 0.00002 mg to about 5 mg of a metabolite of Compound 1, such asCompound 2, or a corresponding amount of a pharmaceutically acceptablesalt thereof. In some embodiments, formulations or pharmaceuticalcompositions of the disclosure comprise about 0.0002 mg to about 0.020mg of a metabolite of Compound 1, such as Compound 2, or a correspondingamount of a pharmaceutically acceptable salt thereof.

In some embodiments, a formulation or pharmaceutical composition of thedisclosure may be administered in a single dose. In some embodiments, aformulation or pharmaceutical composition of the disclosure may beadministered in a divided dose. In some embodiments, an initial dose ofa formulation or pharmaceutical composition of the disclosure providesluteal phase support. In some embodiments, an initial dose of aformulation or pharmaceutical composition of the disclosure is a triggerfor oocyte maturation. In some embodiments, two doses of a formulationor pharmaceutical composition of the disclosure may be administered. Asecond dose of a formulation or pharmaceutical composition of thedisclosure may result in more viable oocytes and better pregnancy ratesfor some women. Further, a second dose may be needed to achieve a fullLH surge and to obtain mature oocytes and could be given in both oocytedonation and banking and IVF/ICSI cycles. In some embodiments, a seconddose may be needed for luteal phase support. In certain suchembodiments, the second dose may be needed in an ART protocol involvingfresh transfer of an embryo. In some embodiments, the second dose isadministered within about 8 to about 60 hours after administration ofthe initial dose. In certain such embodiments, the second dose isadministered within about 8 to about 12 hours after administration ofthe initial dose. In some embodiments, the second dose is administeredwithin about 8 to about 16 hours after administration of the initialdose. In some embodiments, the second dose is administered within about8 to about 24 hours after administration of the initial dose. In someembodiments, the second dose is administered within about 8 to about 32hours after administration of the initial dose. In some embodiments, thesecond dose is administered within about 8 to about 40 hours afteradministration of the initial dose. In some embodiments, the second doseis administered within about 8 to about 48 hours after administration ofthe initial dose. In some embodiments, the second dose is administeredwithin about 8 to about 54 hours after administration of the initialdose. In some embodiments, the second dose is administered within about12 to about 16 hours after administration of the initial dose. In someembodiments, the second dose is administered within about 12 to about 24hours after administration of the initial dose. In some embodiments, thesecond dose is administered within about 12 to about 32 hours afteradministration of the initial dose. In some embodiments, the second doseis administered within about 12 to about 40 hours after administrationof the initial dose. In some embodiments, the second dose isadministered within about 12 to about 48 hours after administration ofthe initial dose. In some embodiments, the second dose is administeredwithin about 12 to about 54 hours after administration of the initialdose. In some embodiments, the second dose is administered within about24 to about 36 hours after administration of the initial dose. In someembodiments, the second dose is administered within about 24 to about 48hours after administration of the initial dose. In some embodiments, thesecond dose is administered within about 24 to about 60 hours afteradministration of the initial dose. In some embodiments, the second doseis administered within about 36 to about 48 hours after administrationof the initial dose. In some embodiments, the second dose isadministered within about 36 to about 60 hours after administration ofthe initial dose. In some embodiments, the second dose is administeredwithin about 48 to about 60 hours after administration of the initialdose.

In some embodiments, three doses of a formulation or pharmaceuticalcomposition of the disclosure may be administered. In some embodiments,the third dose of a formulation or pharmaceutical composition of thedisclosure provides luteal phase support. In some embodiments, the thirddose is administered within about 8 to about 60 hours afteradministration of the second dose. In certain such embodiments, thethird dose is administered within about 8 to about 12 hours afteradministration of the second dose. In some embodiments, the third doseis administered within about 8 to about 16 hours after administration ofthe second dose. In some embodiments, the third dose is administeredwithin about 8 to about 24 hours after administration of the seconddose. In some embodiments, the third dose is administered within about 8to about 32 hours after administration of the second dose. In someembodiments, the third dose is administered within about 8 to about 40hours after administration of the second dose. In some embodiments, thethird dose is administered within about 8 to about 48 hours afteradministration of the second dose. In some embodiments, the third doseis administered within about 8 to about 54 hours after administration ofthe second dose. In some embodiments, the third dose is administeredwithin about 12 to about 16 hours after administration of the seconddose. In some embodiments, the third dose is administered within about12 to about 24 hours after administration of the second dose. In someembodiments, the third dose is administered within about 12 to about 32hours after administration of the second dose. In some embodiments, thethird dose is administered within about 12 to about 40 hours afteradministration of the second dose. In some embodiments, the third doseis administered within about 12 to about 48 hours after administrationof the second dose. In some embodiments, the third dose is administeredwithin about 12 to about 54 hours after administration of the seconddose. In some embodiments, the third dose is administered within about24 to about 36 hours after administration of the second dose. In someembodiments, the third dose is administered within about 24 to about 48hours after administration of the second dose. In some embodiments, thethird dose is administered within about 24 to about 60 hours afteradministration of the second dose. In some embodiments, the third doseis administered within about 36 to about 48 hours after administrationof the second dose. In some embodiments, the third dose is administeredwithin about 36 to about 60 hours after administration of the seconddose. In some embodiments, the third dose is administered within about48 to about 60 hours after administration of the second dose.

In some embodiments, a third dose of a formulation or pharmaceuticalcomposition of the disclosure is administered and is followed byadministration of one to five additional doses. In some embodiments, theone to five additional doses of a formulation or pharmaceuticalcomposition of the disclosure administered after a third dose of aformulation or pharmaceutical composition of the disclosure provideluteal phase support. In some embodiments, the one to five additionaldoses of a formulation or pharmaceutical composition of the disclosureadministered after a third dose of a formulation or pharmaceuticalcomposition of the disclosure are administered after oocyte retrieval.In some embodiments wherein a third dose of a formulation orpharmaceutical composition of the disclosure is administered and isfollowed by administration of one to five additional doses, theadministration of the one to five additional doses is within about 8 toabout 60 hours after the prior dose is administered. In certain suchembodiments, the one to five additional doses are administered withinabout 8 to about 12 hours after administration of the prior dose. Insome embodiments, the one to five additional doses are administeredwithin about 8 to about 16 hours after administration of the prior dose.In some embodiments, the one to five additional doses are administeredwithin about 8 to about 24 hours after administration of the prior dose.In some embodiments, the one to five additional doses are administeredwithin about 8 to about 32 hours after administration of the prior dose.In some embodiments, the one to five additional doses are administeredwithin about 8 to about 40 hours after administration of the prior dose.In some embodiments, the one to five additional doses are administeredwithin about 8 to about 48 hours after administration of the prior dose.In some embodiments, the one to five additional doses are administeredwithin about 8 to about 54 hours after administration of the prior dose.In some embodiments, the one to five additional doses are administeredwithin about 12 to about 16 hours after administration of the priordose. In some embodiments, the one to five additional doses areadministered within about 12 to about 24 hours after administration ofthe prior dose. In some embodiments, the one to five additional dosesare administered within about 12 to about 32 hours after administrationof the prior dose. In some embodiments, the one to five additional dosesare administered within about 12 to about 40 hours after administrationof the prior dose. In some embodiments, the one to five additional dosesare administered within about 12 to about 48 hours after administrationof the prior dose. In some embodiments, the one to five additional dosesare administered within about 12 to about 54 hours after administrationof the prior dose. In some embodiments, the one to five additional dosesare administered within about 24 to about 36 hours after administrationof the prior dose. In some embodiments, the one to five additional dosesare administered within about 24 to about 48 hours after administrationof the prior dose. In some embodiments, the one to five additional dosesare administered within about 24 to about 60 hours after administrationof the prior dose. In some embodiments, the one to five additional dosesare administered within about 36 to about 48 hours after administrationof the prior dose. In some embodiments, the one to five additional dosesare administered within about 36 to about 60 hours after administrationof the prior dose. In some embodiments, the one to five additional dosesare administered within about 48 to about 60 hours after administrationof the prior dose.

The following are examples of embodiments of the disclosure and are notto be construed as limiting.

EXAMPLES

Throughout the Figures and Examples, the term “API-FB” is used to referto the free form of Compound 1. The term “API-MA” is used to refer tothe monoacetate salt form of Compound 1.

Additionally, throughout the Figures and Examples, the dosage amountsused refer to the amount of API-FB present in the formulation. It wouldbe clear to one of skill in the art how to calculate the amount ofAPI-FB taking into account the difference in molecular weight betweenAPI-FB and API-MA. For example, 10.0 mg of API-FB, would correspond to10.5 mg of API-MA.

Baseline levels noted in the Examples refer to an individual's hormonelevels prior to being administered one or more doses of a compound ofthe disclosure.

The activity of API-MA was examined in vitro and in vivo in a series ofpharmacological studies.

In vitro receptor binding studies demonstrated that API-MA has highaffinity for the human KISS1R, with an average IC₅₀ value of 230 pmol/L.In a human GPR54-calcium mobilization assay, the agonist activity ofAPI-MA had a concentration producing a half maximal effectiveconcentration (EC₅₀) of 266 pmol/L. The kisspeptin (45-54) EC₅₀ was 314pmol/L.

Example 1: In Vitro Pharmacology

Binding Affinity of API-MA for KISS1R:

The binding affinity of API-MA to membrane fractions ofKISS1R-expressing recombinant cells was examined in a competitivebinding assay. Varying concentrations of API-MA and ¹²⁵I-kisspeptin(45-54) were incubated with the membrane fractions of recombinant cellsexpressing rat, dog, monkey, and human KISS1R.

The results of receptor binding studies showed that the binding affinityof API-MA to KISS1R of the species tested varied, with an IC₅₀ valueranging from 230 to 870 pmol/L. In recombinant Chinese hamster ovarycells (cell line h175-KB34) expressing the human KISS1R, the IC₅₀ valuefor API-MA was approximately 2.5 times higher than that for kisspeptin(45-54), the C-terminal 10 amino acid residue peptide of kisspeptin,with an IC₅₀ value of 230 pmol/L for API-MA versus 93 pmol/L forkisspeptin (45-54).

Example 2: Effects of API-MA on Intracellular Ca²⁺ Levels in ChineseHamster Ovary Cells Expressing KISS1R

The effects of API-MA on intracellular Ca²⁺ mobilization inKISS1R-expressing recombinant cells were evaluated by performing thefluorometric imaging plate reader assay. API-MA increased intracellularCa²⁺ levels in Chinese hamster ovary dihydrofolate reductase negativecells expressing rat, dog, monkey, or human KISS1R in a concentrationdependent manner. The EC₅₀ values of API-MA in cells expressing rat,dog, monkey, or human type receptor were 632, 2010, 74.0, and 266pmol/L, respectively. A reference compound, kisspeptin (45-54), showedEC₅₀ values of 310, 1680, 78.7, and 314 pmol/L, respectively. The ratiosof EC₅₀ values of API-MA to that of kisspeptin (45-54), were 2.0, 1.2,0.94, and 0.85 for cells expressing each type of receptor, respectively.These results suggest that the agonistic activity of API-MA to KISS1R isas potent as that of kisspeptin (45-54).

Secondary Pharmacodynamics:

In a series of 127 enzyme and radio ligand binding assays, API-MA, at 10μmol/L, did not show any significant inhibitory effect in the indicatedenzyme and receptor binding assays.

Example 3: Pharmacokinetics and Drug Metabolism in Animals

The PK of API-MA was studied in rats, dogs, and monkeys. After SCadministration, API-MA was rapidly absorbed, and the bioavailability ofAPI-MA was good across species (>55%).

In Vitro Distribution and Metabolism Studies:

The in vitro distribution ratios of [¹⁴C]API-MA into the blood cells atthe concentrations of 0.01, 0.1, 1, and 10 μg/mL API-FB (free form) were7.8%, 8.0%, 7.1%, and 4.8% for rats, 2.4%, 2.0%, 1.6%, and 1.2% fordogs, and 2.0%, 0.0%, 0.0%, and 0.5% for humans, respectively. Theseresults indicated that the distribution ratios of API-FB into the bloodcells were low and almost constant in the concentration range of 0.01 to10 μg/mL as API-FB in rats, dogs, and humans. The in vitro plasmaprotein binding ratios of [¹⁴C]API-FB in rats, dogs, monkeys, and humanswere determined by the ultracentrifugation method. In addition, theprotein binding to human serum albumin (HSA), α₁-acid glycoprotein(AGP), and HSA/AGP was investigated. The results from this studyindicated that the plasma protein binding of API-FB was moderate in allspecies examined (range from 55.3% to 73.3%). In rats and dogs, a slightdecrease in the binding ratio at the concentration range between 0.1 and1.0 μg/mL API-FB was observed. In monkeys and humans, the binding wasindependent of the drug concentrations from 0.01 to 10 μg/mL API-FB. Thebinding ratio in the HSA/AGP mixture was lower than in human plasma and,unlike human plasma, the ratio had a tendency to decline in aconcentration dependent manner, suggesting that API-FB bound not only toalbumin and α₁-acid glycoprotein but also to other protein(s) in humanplasma.

Inhibition of CYP by API-MA was evaluated in vitro using recombinantCYPs; the data (IC₅₀ values >10 μg/L) indicate that API-MA is unlikelyto be an inhibitor of CYP1A2, CYP2B6, CYP2C8, CYP2C9, CYP2C19, CYP2D6,or CYP3A4.

Pharmacokinetics in Rats:

The PK of API-MA was studied in rats after SC and IV administration. ThePK profile of API-MA in rats is summarized in Table 1.

After SC administration of API-MA at doses of 1 and 10 mg/kg, theincrease in the maximum observed plasma concentration (C_(max)) ofAPI-FB in plasma was less than dose-proportional (˜2.3 times increase).The mean values were 381.3 and 284.6 ng/mL, respectively. On the otherhand, the increase in area under the plasma concentration-time curvefrom time 0 to 24 hours (AUC₍₀₋₂₄₎) of API-FB after SC administration of10 mg/kg was >2.5 times less than those observed at 1 mg/kg. The meanvalues for 10 and 1 mg/kg doses were 309 and 804 ng·hr/mL, respectively.The reason the C_(max) and AUC values in rats were not dose-proportionalis unknown. However, the time to reach the maximum observed plasmaconcentration (T_(max)) was roughly constant for all tested doses;values were between 0.3 and 0.9 hours. The terminal eliminationhalf-life (T_(1/2)) was not determined due to the limited number of datapoints.

After IV administration of API-MA at a dose of 1 mg/kg, the plasmaconcentration at 5 minutes (C_(5min)) was 2672.3 ng/mL. Theconcentration then decreased biphasically, with a T_(1/2) of 0.5 hoursfor the alpha phase. The T_(1/2) for the beta phase was not calculatedbecause of the limited number of data points. The AUC₍₀₋₂₄₎ value was1457 ng·hr/mL.

The bioavailability of an SC dose of 1 mg/kg of API-MA in rats was good(55.3%).

The PK linearity of API-MA was also investigated in rats after IVadministration. The plasma C_(5min) and AUC₍₀₋₂₄₎ values increaseddose-proportionally. The values for plasma C_(5min) were 24.1, 250.0,and 2577.8 ng/mL and those for AUC₍₀₋₂₄₎ were 14, 140, and 1390 ng·hr/mLat doses of 0.01, 0.1, and 1 mg/kg, respectively. The eliminationT_(1/2) values were 0.4 hours at 0.01 and 0.1 mg/kg and 0.5 hours at 1mg/kg. These findings indicate that the PK of API-FB was linear in ratsafter single IV administration over the dose range of 0.01 to 1 mg/kg.The greater than dose-proportional increase in the first-pass kineticswith SC administration would indicate nonlinear PK in rats after SCadministration.

TABLE 1 PK Parameters of API-FB in Rats Dose Dose (a) Tmax CmaxAUC(0-24) AUC/Dose BA (b) Route (mg/kg) (hr) (ng/mL) (ng · hr/mL) (10⁻⁶kg · hr/mL) (%) SC 0.1 0.5 ± 0.0  90.0 ± 12.5 123 ± 9  1234 ± 92  — 10.9 ± 0.2  381.3 ± 75.5  804 ± 133  804 ± 133 55.3 ± 8.6 10 0.3 ± 0.0 284.6 ± 58.6 309 ± 70 31 ± 7 — IV 1 — 2672.3 ± 234.3 (c) 1457 ± 143 — —— = not estimated; BA = bioavailability. Mean value ± standard deviation(SD) (n = 5). (a) Vehicle is a mixture of dimethyl acetamide and 5%glucose solution (1:9, vol/vol). (b) BA = (AUC SC/AUC IV) × (DoseIV/Dose SC) × 100. (c) C5 min.

The concentrations of the radioactivity in the tissues of male albinoand pigmented rats were investigated after a single IV administration of[¹⁴C]API-MA at 1.049 mg/kg (1 mg/kg API-FB). The results of this studyshowed that API-MA-related compounds were distributed widely into thetissues, with lower concentrations than in the plasma in most of thetissues except for the kidneys and urinary bladder. The radioactivity,measured in albino rats, was rapidly eliminated from all of the tissuesafter IV administration of API-MA. It was also indicated thatAPI-MA-related compounds had little affinity for melanin in vivo.

The urinary, fecal, biliary, and expiratory excretion of the dosedradioactivity was investigated after a single SC or IV administration of[¹⁴C]API-MA at 1.049 mg/kg (1 mg/kg API-FB) to male Sprague-Dawley ratsin two studies.

In the first study, urinary, fecal, and biliary excretions wereinvestigated. After SC or IV administration, API-MA was mainly excretedin urine (84.7% and 76.6%, respectively), followed by bile (15.5% and20.7%, respectively) and feces (0.2% and 0.3%, respectively) at 24 hourspostdose.

In the second study, urinary, fecal, and expiratory excretions wereinvestigated. After SC or IV administration, API-MA was mainly excretedin urine (78.1% and 70.0%, respectively) and feces (20.4% and 28.2%,respectively) at 48 hours postdose. The excretion via expiration wasminimal. The results from this study also indicate that the excretionwas almost completed by 48 hours postdose after SC or IV administrationof [¹⁴C]API-MA to rats.

Pharmacokinetics in Dogs:

The PK of API-MA was studied in dogs after SC and IV administration. ThePK profile of API-MA in dogs is summarized in Table 2 below.

After SC administration of API-MA to dogs, plasma C_(max) and AUC₍₀₋₂₄₎values increased in a dose-proportional manner over the dose range of0.1 to 10 mg/kg. The plasma C_(max) values were 86.6, 882.7, and 8842.5ng/mL and the plasma AUC₍₀₋₂₄₎ values were 252, 2596, and 28,626ng·hr/mL at the doses of 0.1, 1, and 10 mg/kg, respectively. The plasmaT_(max) values were within 0.8 to 1.0 hours for the tested doses.

After a bolus IV administration of API-MA at a dose of 1 mg/kg, theplasma C_(5min) value was 4254.4 ng/mL, and the concentration decreasedwith a triphasic time course. The elimination T_(1/2) value was 3.0hours. The AUC₍₀₋₂₄₎ value was 3093 ng·hr/mL.

The bioavailability of API-MA after SC administration was good, withestimated values of 81.5%, 84.0%, and 92.7% at the doses of 0.1, 1, and10 mg/kg, respectively.

On the basis of these results, although SC-administered API-MA underwentslight first-pass kinetics before absorption, API-MA was well absorbedin dogs, and the PK of API-MA showed a dose-proportional increase in thedose range from 0.1 to 10 mg/kg.

TABLE 2 PK Parameters of API-FB in Dogs Dose Dose (a) Tmax Cmax T½ (hr)AUC(0-24) AUC/Dose BA (b) Route (mg/kg) (hr) (ng/mL) α β γ (ng · hr/mL)(10⁻⁶ kg · hr/mL) (%) SC 0.1 0.8 ± 0.3  86.6 ± 19.0 ND 1.4 ± 0.2 NC 252± 34 2518 ± 339  81.5 ± 11.5 1 0.8 ± 0.3  882.7 ± 251.3 ND 1.4 ± 0.3 2.6± 0.2 2596 ± 219 2596 ± 219 84.0 ± 8.1 10 1.0 ± 0.0 8842.5 ± 1202.1 ND1.5 ± 0.4 2.6 ± 0.1 28,626 ± 1814  2863 ± 181 92.7 ± 7.7 IV 1 — 4254.4 ±543.4 (c) 0.2 ± 0.0 1.1 ± 0.0 3.0 ± 0.1 3093 ± 80  — — — = notestimated; BA = bioavailability; NC = not calculated; ND = not detected.Mean value ± SD (n = 4). (a) Vehicle is a mixture of dimethyl acetamideand 5% glucose solution (1:9, vol/vol). (b) BA = (AUC SC/AUC IV) × (DoseIV/Dose SC) × 100. (c) C5 min.

Pharmacokinetics in Monkeys:

The PK of API-MA was studied in monkeys after SC and IV administration.The PK profile of API-MA in monkeys is summarized in Table 3 below.

After SC administration to monkeys, C_(max) and AUC₍₀₋₂₄₎ valuesincreased in a dose-proportional manner over the dose range of 0.1 to 10mg/kg. The plasma C_(max) values were 122.6, 1323.4, and 12,089.6 ng/mL,and for the plasma AUC₍₀₋₂₄₎, values were 295, 2791, and 31,576 ng·hr/mLat the doses of 0.1, 1, and 10 mg/kg, respectively. The T_(max) valueswere within 0.3 to 0.4 hours for the tested doses. After reachingC_(max), the concentrations decreased. A multi-exponential decline wasnoted after IV administration with mean terminal elimination T_(1/2) ofapproximately 2.6 hours, which was similar to that obtained after IVadministration. The steep distribution phase was not evident after SCdosing because the slow absorption of API-MA from the SC injection sitepartially masked the distribution phase.

After bolus IV administration of API-MA at a dose of 1 mg/kg, the plasmaC_(5min) value was 5027.0 ng/mL, and the concentration decreased with atriphasic time course. The elimination T_(1/2) value was 3.2 hours. TheAUC₍₀₋₂₄₎ value was 3160 ng·hr/mL.

The SC bioavailability of API-MA was good, with values of 94.9%, 90.1%,and 101.9% at doses of 0.1, 1.0, and 10 mg/kg, respectively.

These results indicate that API-MA was well absorbed in monkeys andthat, when administered SC, API-MA underwent minimal or no first-passeffect before absorption. The PK of API-MA showed a dose-proportionalincrease in monkeys in the dose range from 0.1 to 10 mg/kg.

TABLE 3 PK Parameters of API-FB in Dogs Dose Dose (a) Tmax Cmax T½ (hr)AUC(0-24) AUC/Dose BA (b) Route (mg/kg) (hr) (ng/mL) α β γ (ng · hr/mL)(10⁻⁶ kg · hr/mL) (%) SC 0.1 0.4 ± 0.1   122.6 ± 27.3 ND 1.6 ± 0.3 NC295 ± 27 2950 ± 266 94.9 ± 12.4 1 0.3 ± 0.0   1323.4 ± 316.1 ND 1.4 ±0.2 2.5 ± 0.2 2791 ± 262 2791 ± 262 90.1 ± 15.4 10 0.4 ± 0.1 12,089.6 ±2370.2 ND 1.5 ± 0.3 2.6 ± 0.3 31,576 ± 1396  3157 ± 140 101.9 ± 14.3  IV1 —   5027.0 ± 786.7 (c) 0.3 ± 0.0 1.2 ± 0.1 3.2 ± 0.1 3160 ± 594 NE NEBA = bioavailability; NC = not calculated; ND = not detected; NE = notestimated. Mean value ± SD (n = 4). (a) Vehicle is a mixture of dimethylacetamide and 5% glucose solution (1:9, vol/vol). (b) BA = (AUC SC/AUCIV) × (Dose IV/Dose SC) × 100. (c) C5 min.

Pharmacokinetics and Product Metabolism:

The following PK parameters are summarized for plasma and urine API-MA,as appropriate, following administration of API-MA:

-   -   C_(max), maximum observed plasma concentration.    -   T_(max), time to reach C_(max).    -   C_(SS), steady-state plasma concentration.    -   AUC₍₀₋₂₄₎, area under the plasma concentration-time curve (AUC)        from time 0 to 24 hours.    -   AUC_((0-inf)), AUC from time 0 to infinity.    -   T_(1/2), terminal elimination half-life.    -   CL/F, apparent clearance (after subcutaneous [SC] dosing).    -   Fe, fraction of dose excreted in urine.

Example 4: Summary of Studies

Single Dose PK—Summary:

In Japanese men, systemic exposure to API-MA, measured as C_(max) andAUC_((0-inf)), increased dose-proportionally over the single dose rangestudied, 0.001 to 0.5 mg. Mean CL/F ranged from 13.7 to 19.8 L/hr.Median T_(max) for SC bolus administration of API-MA ranged from 0.375to 0.750 hour, suggesting rapid systemic uptake of API-MA from the SCdosing site. In general, mean T_(1/2) values increased with increasingdose. This can be attributed to API-MA concentrations below the limit ofquantitation of assay resulting in underestimation of T_(1/2) andapparent dose dependency of this parameter after administration of lowdoses of API-MA. At the highest doses studied, 0.25 and 0.5 mg, meanT_(1/2) was 3.77 to 4.27 hours. Mean Fe ranged from 4.24% to 7.10% ofthe administered dose for doses from 0.004 to 0.5 mg.

Based on PK data from a phase 1 study of API-MA conducted in Europeanmen, AUC_((0-inf)) increased dose-proportionally after theadministration of single SC doses of 0.001 to 0.3 mg and 2-hour SCinfusion of 1, 3, and 6 mg. The CL/F values ranged from 18.9 to 27.1L/hr following single SC bolus and 2-hour infusion doses of API-MA.Median T_(max) for SC bolus administration of API-MA ranged from 0.5 to0.750 hour, indicating rapid systemic uptake of API-MA from the SCdosing site, which was not dose dependent over the SC dose rangeevaluated in this study. At the highest doses studied, 3 and 6 mg, meanT_(1/2) was approximately 5.2 hours and generally increased withincreasing dose. Fe ranged from 3.09% to 5.40% of the administered dosefor doses from 0.003 to 6 mg.

Multiple-Dose PK—Summary:

In a phase 1 study of prolonged (continuous over 13 days) SC INF ofAPI-MA, the C_(SS) of API-MA increased in an apparent dose-proportionalfashion and the mean CL/F values ranged from 17.7 to 20.6 L/hr over thedose range evaluated (0.01 to 1 mg). In a study of hormone-naïveJapanese prostate cancer patients, API-MA was administered at doses of0.5 or 1.0 mg/day as a 2-hour SC infusion for 14 days. Plasmaconcentrations of API-MA increased and reached Cmax immediately afterthe end of infusion, and then declined with a mean T_(1/2) value ofabout 3 to 4 hours on both days 1 and 14 at both doses. There was anapproximate dose-proportional increase in exposure of API-MA 0.5 and 1.0mg/day doses via SC infusion. No accumulation of API-MA was observedafter multiple SC administration for 14 days.

1-Month Depot Summary:

In another study, prostate cancer patients who were either on GnRHagonist therapy or were potential future candidates for GnRH agonisttherapy received either 6, 12, or 24 mg as a single 1-month depotinjection (N=3 per dose group). A high-burst release of API-MA drugconcentrations was observed within hours after administration of depotinjection. The AUC₍₀₋₂₄₎ comprised over 60% of the area under the plasmaconcentration-time curve from time 0 to the time of last quantifiableconcentration (AUC_((0-tlqc))) observed, showing a significant releaseof drug from formulation during the burst phase. Very low levels of drugconcentrations were present over the next several days followed by aslow rise, consistent with presumed delayed and slow release from theformulation. In all cases, API-MA was not detectable by 8 weekspostdose.

Single Dose Pharmacokinetics of API-MA:

This study was conducted in Japan as a randomized, double-blind,placebo-controlled, parallel-group, ascending dose study to evaluateAPI-MA safety, plasma and urine PK, and endocrine PD effects followingadministration of single SC bolus doses (0.001-0.5 mg) or a 2-hour SCinfusion (0.25 and 0.5 mg) that was expected to stimulate testosteronelevels. Thirty-seven healthy Japanese male subjects aged 50 to 74 yearswere enrolled into nine cohorts. Subjects enrolled in the first sevencohorts received 0.001, 0.004, 0.01, 0.04, 0.1, 0.25 or 0.5 mg of API-MAor placebo by single SC bolus. In the 0.001 mg cohort, 3 subjectsreceived API-MA and two received placebo. In the remaining cohorts, 3subjects received API-MA and one received placebo. Subjects enrolled inthe eighth and ninth cohorts received 0.25 or 0.5 mg of API-MA orplacebo by single 2-hour SC infusion. In both cohorts, 3 subjectsreceived API-MA and one received placebo. The plasma PK analysis setconsisted of 31 subjects (bolus cohorts: 25; infusion cohorts: 6), andthe urine PK analysis set consisted of 35 subjects (bolus cohorts: 27;infusion cohorts: 8).

To measure plasma concentrations of API-MA in subjects in the SC boluscohorts, blood specimens were collected at the following nominal times:predose, 0.083, 0.25, 0.5, 0.75, 1, 2, 3, 4, 6, 8, 12, 16, 24, 36, 48and 72 hours postdose. To measure urinary excretion of API-MA, urinespecimens were collected at the following nominal times: predose, 0 to4, 4 to 8, 8 to 12, 12 to 24, 24 to 36, 36 to 48 and 48 to 72 hourspostdose.

To measure plasma concentrations of API-MA in subjects in the SCinfusion cohorts, blood specimens were collected at the followingnominal times: predose and 0.25, 0.5, 1, 2, 2.25, 2.5, 2.75, 3, 4, 5, 6,8, 10, 14, 24, 36, 48 and 72 hours after the start of the infusion. Tomeasure urinary excretion of API-MA, urine specimens were collected atthe following nominal times: predose and 0 to 4, 4 to 8, 8 to 12, 12 to24, 24 to 36, 36 to 48 and 48 to 72 hours after the start of theinfusion.

The mean plasma and urine PK parameter values for single dose API-MAadministered by SC bolus and for single dose API-MA administered by2-hour SC infusion are listed in Table 4 below.

TABLE 4 Mean Single Dose SC Bolus and Single Dose 2-Hour SC Infusion PKParameters Dose (mg) Single-Dose SC Bolus Parameter 0.001 0.004 0.010.04 0.1 Plasma N 2 3 3 3 2 Cmax 20.1 (3.3)  6.17 (9.1)  221 (28)  966(230) 2415 (318)  (pg/mL) Tmax (a)     0.5 (0.5-0.5)      0.5 (0.5-0.75)     0.5 (0.5-0.75)      0.5 (0.25-0.5)     0.375 (0.25-0.5) (hr) AUC(0-inf) 54.1 (3.7)  205 (33)  671 (49)  2606 (868)  5785 (1463) (hr ·pg/mL) T½ (hr) 1.59 (0.08) 1.91 (0.25) 1.82 (0.13) 3.35 (1.00) 3.58(0.88) CL/F (L/hr) 18.6 (1.3)  19.8 (3.3)  15.0 (1.1)  16.7 (6.1)  17.9(4.5)  Urine N 2 3 3 3 3 Fe (%) 0 (0) 6.16 (1.48) 5.40 (1.16) 4.24(1.51) 5.20 (1.19) Dose (mg) Single-Dose 2-Hour Single-Dose SC Bolus SCINF Parameter 0.25 0.5 0.25 0.5 Plasma N 2 3 1 3 Cmax 5895 (247)  9050(1429)  4020 (NC) 8230 (1500) (pg/mL) Tmax (a)      0.75 (0.75-0.75)     0.5 (0.5-0.75)   2.25 (2.25-2.25)      2.5 (2.5-2.75) (hr) AUC(0-inf) 18320 (1713)  29970 (3950)  13280 (NC) 34650 (4181) (hr · pg/mL)T½ (hr) 4.09 (0.33) 4.27 (0.56)   3.77 (NC) 4.02 (0.45) CL/F (L/hr) 13.7(1.3)  16.9 (2.4)    18.8 (NC) 14.6 (1.8)  Urine N 3 3 3 3 Fe (%) 7.10(0.46) 6.33 (0.54)   6.21 (1.94) 5.22 (2.04) NC = not calculated. (a)Median (range).

Following a single SC bolus of API-MA, systemic exposure to API-MA,measured as C_(max) and AUC_((0-inf)), increased dose-proportionallyover the dose range studied, 0.001 to 0.5 mg. Dose-proportionality wasassessed formally by fitting a power model to the data. The pointestimate for the power exponent was 1.023 for C_(max) (95% confidenceinterval [CI], 0.970-1.076) and 1.027 for AUC_((0-inf)) (95% CI,0.979-1.075). Mean C_(max) and AUC_((0-inf)) values following 2-hour SCinfusion of 0.5 mg of API-MA were similar to the mean values followingan SC bolus (8230 versus 9050 pg/mL and 34650 versus 29970 hr·pg/mL,respectively). Note that there was only one subject in the 0.25 mginfusion cohort. The mean CL/F ranged from 13.7 to 19.8 L/hr followingadministration of single bolus and 2-hour SC infusion doses of API-MA.

Median T_(max) for SC bolus administration of API-MA ranged from 0.375to 0.750 hour, suggesting rapid systemic uptake of API-MA from the SCdosing site. The rapid uptake of API-MA did not appear to be dosedependent.

In general, mean T_(1/2) values increased with increasing dose. This canbe attributed to API-MA concentrations below the limit of quantitationof assay resulting in underestimation of T_(1/2) and apparent dosedependency of this parameter after administration of low doses ofAPI-MA. At the highest doses studied (0.25 and 0.5 mg), mean T_(1/2) was3.77 to 4.27 hours.

No API-MA was detected in the urine following a single SC bolus of 0.001mg API-MA. Across the higher dose bolus and infusion cohorts (0.004 to0.5 mg), mean single dose Fe ranged from 4.24% to 7.10% of theadministered dose of API-MA. Plots of the cumulative urinary excretionof API-MA showed that excretion was essentially complete by 24 hours.

Example 5: Pharmacodynamic Effects of API-MA Administered as a SC Bolus

Another study was a phase 1 randomized, double-blind,placebo-controlled, parallel-group, ascending dose study of the safety,tolerability, plasma and urine PK, and endocrine pharmacodynamic effectsof API-MA administered as a SC bolus (0.001-0.3 mg) or a 2-hour SCinfusion (1-6 mg) that was expected to stimulate testosterone. The studywas conducted in France.

Eighty-two healthy European male subjects aged 50 to 76 years wereenrolled into nine cohorts. 81/82 subjects (98.8%) were white and 1/82subject (1.2%) was black/African American. Subjects enrolled in thefirst six cohorts received 0.001, 0.003, 0.01, 0.03, 0.1, or 0.3 mg ofAPI-MA or placebo by single SC bolus. In the 0.3 mg cohort, 6 subjectsreceived API-MA and two received placebo. In the remaining cohorts, 7subjects received API-MA and three received placebo. Subjects enrolledin the seventh, eighth, and ninth cohorts received 1, 3, or 6 mg ofAPI-MA or placebo by single 2-hour SC infusion. In these cohorts, 6subjects received API-MA and two received placebo.

To measure plasma concentrations of API-MA in subjects in the SC boluscohorts, blood specimens were collected at the following nominal times:predose and 0.083, 0.25, 0.5, 0.75, 1, 2, 3, 4, 6, 8, 12, 16, 24, 36, 48and 72 hours postdose. To measure urinary excretion of API-MA, urinespecimens were collected at the following nominal times: from 12 hoursprior to dosing until dosing and 0 to 6, 6 to 12, 12 to 24, 24 to 48 and48 to 72 hours postdose.

To measure plasma concentrations of API-MA in subjects in the SCinfusion cohorts, blood specimens were collected at the followingnominal times: predose and 0.5, 1, 1.5, 2, 2.25, 2.5, 3, 4, 6, 8, 10,14, 18, 26, 50 and 74 hours after the start of the infusion. To measureurinary excretion of API-MA, urine specimens were collected at thefollowing nominal times: from 12 hours prior to dosing until dosing and0 to 6, 6 to 12, 12 to 24, 24 to 48, and 48 to 72 hours after the startof the infusion.

Mean plasma API-MA concentration-time curves following a single SCadministration of API-MA at doses ranging from 0.001 to 6 mg are shownin FIG. 2. The mean percent coefficient of variation (% CV) plasma andurine PK parameter values for single dose API-MA administered by SCbolus and for single dose API-MA administered by 2-hour SC infusion arelisted in the following Tables 5 to 8.

TABLE 5 Mean (% CV) Plasma PK Parameters Following a Single SCAdminstration of API-MA at Doses Ranging From 0.001 to 0.3 mg GeometricMean (% CV) (a) 0.001 mg 0.003 mg 0.01 mg 0.03 mg 0.1 mg 0.3 mgParameter (N = 7) (N = 7) (N = 7) (N = 7) (N = 7) (N = 6) Cmax (pg/mL)13.253 42.384 140.140 340.182 1382.196 4349.244 (19.10) (30.36) (44.26)(17.60) (26.77) (34.08) AUC (0-inf) 47.459 122.246 370.975 1108.0963943.856 13213.549 (hr · pg/mL) (33.78) (16.03) (26.81) (20.49) (14.92)(25.03) AUC (0-tlqc) 26.693 100.915 345.193 1069.885 3887.968 13155.656(hr · pg/mL) (21.64) (20.18) (28.87) (20.65) (14.81) (25.06) T½ (hr) (b)1.796 1.425 2.172 2.610 3.079 3.451 (1.20-4.58) (1.18-2.34) (1.82-2.72)(1.50-3.11) (2.29-3.56) (2.98-4.10) Tmax (hr) (b) 0.500 0.750 0.5000.500 0.500 0.625 (0.25-1.00) (0.50-1.00) (0.25-0.75) (0.25-0.75)(0.25-0.75) (0.25-0.75) CL/F (L/hr) 21.071 24.541 26.956 27.073 25.35622.704 (33.78) (16.03) (26.81) (20.49) (14.92) (25.03) Vz/F (L) 63.92555.862 85.629 95.981 108.017 114.225 (27.13) (34.30) (34.48) (14.77)(21.08) (32.60) Vz/F = apparent volume of distribution. (a) CV (%) = 100× √(exp(SDlog2) − 1) where SDlog is the standard deviation oflog-transformed values. (b) Median (minimum-maximum) values.

TABLE 6 Mean (% CV) Plasma PK Parameters Following a 2-Hour INF ofAPI-MA at Doses Ranging From 1 to 6 mg Geometric Mean (% CV) (a) 1 mg 3mg 6 mg Parameter (N = 6) (N = 6) (N = 6) Cmax (pg/mL) 13050.559 (20.79)39402.798 (14.80) 82477.820 (22.63) AUC (0-inf) 43825.188 (25.51)141488.720 (11.42) 317753.435 (25.60) (hr · pg/mL) AUC (0-tlqc)43656.011 (25.51) 141392.642 (11.41) 317666.507 (25.60) (hr · pg/mL)T1/2 (hr) (b) 3.643 (3.46-3.83) 5.249 (3.19-5.86) 5.264 (4.56-5.62) Tmax(hr) (b) 2.250 (2.00-2.25) 2.250 (2.25-2.50) 2.250 (2.00-2.50) CL/F(L/hr) 22.818 (25.51) 21.203 (11.42) 18.883 (25.60) Vz/F (L) 119.955(27.97) 149.910 (28.78) 140.984 (28.67) Vz/F = apparent volume ofdistribution. (a) CV (%) = 100 × √(exp(SDlog2) − 1) where SDlog is thestandard deviation of log-transformed values. (b) Median(minimum-maximum) values.

TABLE 7 Mean (% CV) Urine PK Parameters Following a Single SCAdminstration of API-MA at Doses Ranging From 0.001 to 0.3 mg GeometricMean (% CV) 0.001 mg 0.003 mg 0.01 mg 0.03 mg 0.1 mg 0.3 mg Parameter (N= 7) (a) (N = 7) (N = 7) (N = 7) (N = 7) (N = 6) CLr (L/hr) 1048.5461180.964 1073.430 937.560 1048.697 860.937 (15.74) (21.35) (30.52)(24.89) (41.44) Ae(0-t) (ng) 34.658 119.177 370.540 1003.082 4077.29811326.187 (17.70) (20.69) (31.55) (28.29) (30.17) Fe (%) 3.466 3.9733.705 3.344 4.077 3.775 (17.70) (20.69) (31.56) (28.29) (30.17) (a) Only1 subject with a concentration above lower limit of quantification(LLOQ), 6 subjects were set to 0. Ae(0-t) = amount of drug excreted inurine from time 0 time t, CLr = renal clearance.

TABLE 8 Mean (% CV) Urine PK Parameters Following a 2-Hour INF of API-MAat Doses Ranging From 1 to 6 mg Geometric Mean (% CV) Param- 1 mg 3 mg 6mg eter (N = 6) (N = 6) (N = 6) CLr  686.544 (29.02)   835.762 (45.31) 1016.230 (27.70) (L/hr) Ae (0-t) 29971.789 (27.97) 118170.544 (41.46)322822.342 (10.34) (ng) Fe (%)   2.997 (27.97)    3.939 (41.46)    5.380(10.34) Ae (0-t) = amount of drug excreted in urine from time 0 time t,CLr = renal clearance.

The peak concentration of API-MA (C_(max)) increased dose-proportionallyfollowing administration of single SC bolus doses ranging from 0.001 to0.3 mg. The systemic exposure of API-MA measured as AUC_((0-inf))increased dose-proportionally after the administration of single SCdoses of 0.001 to 0.3 and 2-hour SC infusion of 1, 3, and 6 mg. Theestimated exponents of the power equation were 1.003 for C_(max) (95%CI, 0.956-1.050) and 1.019 for AUC_((0-inf)) (95% CI, 0.997-1.040). TheCL/F values ranged from 18.9 to 27.1 L/hr following single SC bolus and2-hour infusion doses of API-MA.

Median T_(max) for SC bolus administration of API-MA ranged from 0.5 to0.750 hour, indicating rapid systemic uptake of API-MA from the SCdosing site. The rapid SC uptake of API-MA was not dose dependent overSC dose range evaluated in this study.

In general, mean T_(1/2) values increased with increasing dose.Examination of FIG. 2 suggests that the likely reason for the longerT_(1/2) can potentially be attributed to the assay sensitivity and theinclusion of measurable API-MA concentrations at the terminal portion ofthe curve in the estimation of T_(1/2) at higher doses. Hence theobserved dose dependency of this parameter does not represent nonlinearpharmacokinetics for API-MA. At the highest doses studied, 3 and 6 mg,mean T_(1/2) was approximately 5.2 hours.

Only a small amount of API-MA was detected in the urine following asingle SC bolus of 0.001 mg API-MA. The mean (CV %) Fe for this cohortwas 3.466%. Across the other dose bolus and infusion cohorts (0.003 to 6mg), mean single dose Fe ranged from 2.997% to 5.380% of theadministered dose of API-MA.

Example 6: Multiple-Dose Pharmacokinetics of API-MA

Another study was a phase 1 clinical study of multiple-doseadministration of API-MA. The study was conducted in France. It was arandomized, double-blind, placebo-controlled, parallel-group, ascendingdose study of the safety, tolerability, plasma PK, and endocrinepharmacodynamic effects of API-MA administered as an SC bolus (0.1 mg)on day 1 followed by continuous SC infusion (i.e., 24 hr/day) from Day 2to Day 14 (0.01, 0.1, 0.3, or 1.0 mg/day), which was expected tosuppress testosterone. Thirty healthy European male subjects aged 50 to78 years were enrolled into four cohorts; 29/30 subjects (96.7%) werewhite and one subject (3.3%) was black.

To measure plasma concentrations of API-MA following SC bolusadministration, blood specimens were collected at the following nominaltimes: predose and 0.083, 0.25, 0.5, 0.75, 1, 2, 4, 6, 12, 16, and 24hours postdose. During SC infusion, blood specimens were collected atthe following nominal times: 6, 12, 24, 54, 60, 72, 150, 156, 168, 222,228, 240, 294, 300, and 312 hours following the start of the infusion.

The mean plasma PK parameter values for single dose API-MA administeredby SC bolus are listed in Table 9 by dosing group for comparison withvalues after continuous 13-day SC INF on Days 2-14, as shown in Table 7.Because the single dose PK of API-MA could be assessed for only 24 hoursbefore infusion of API-MA was begun, the only PK parameters that couldbe estimated were C_(max), T_(max), and AUC₍₀₋₂₄₎. The interindividualvariability for the PK parameters was generally low, with % CV ≤58%.

TABLE 9 Mean (% CV) PK Parameters by Dosing Group Following Single DoseSC Bolus (0.1 mg) on Day 1 Geometric Mean (% CV) Parameter 0.01 mg/day0.1 mg/day 0.3 mg/day 1.0 mg/day N 6    6    6    5    C_(max) (pg/mL)1870 (27) 1590 (31) 1650 (26) 1290 (58) T_(max) (hr) (a) 0.500 0.5000.500 0.500 (0.500, 0.750) (0.250, 1.000) (0.250, 1.033) (0.250, 0.750)AUC (0-tlqc) (hr · pg/mL) 5080 (22) 4280 (12) 4680 (27) 4050 (29) Note:All groups received SC bolus (0.1 mg) on Day 1; dosing group indicateswhich randomized dose subjects received by SC INF from Day 2 to Day 14(0.01-1.0 mg/day). (a) Median (range). (b) AUC (0-tlqc), in this case,is equal to AUC (0-24).

The mean plasma PK parameter values for API-MA administered bycontinuous 13-day SC infusion on Days 2-14 are listed in Table 7. TheC_(SS) increased in an apparent dose-proportional fashion over the doserange studied, 0.01 to 1.0 mg. Across the cohorts, CL/F ranged from 17.7to 20.6 L/hr. The interindividual variability for the PK parameters waslow, with CV %≤40%.

TABLE 10 (% CV) PK Parameters During Continuous 13-Day SC INF of API-MA(Days 2-14) Geometric Mean (% CV) Parameter 0.01 mg/day 0.1 mg/day 0.3mg/day 1.0 mg/day N 6 6 6 5 Css (pg/mL) 20.2 (34)  226 (17)  708 (19)2280 (16) CL/F (L/hr) 20.6 (40) 18.5 (18) 17.7 (18)  18.3 (16) Css =estimated as AUC (Day 2-Day 14)/actual time elapsed from collection ofDay 2, 6-hours specimen until collection of Day 14, 24-hours specimen.

Another study was a phase 1 clinical study of multiple-doseadministration of API-MA. It was an open-label, ascending dose study ofAPI-MA administered via 2-hour SC infusion once daily for 14 days thatwas expected to suppress testosterone in Japanese hormone-naïve prostatecancer patients. Six patients received API-MA at doses of 0.5 mg (3patients) and 1.0 mg (3 patients) a day for 14 days.

To measure plasma concentrations of API-MA, blood specimens werecollected at the following times: Day 1 (predose and 2, 4, 6, 10 hourspostdose); days 2, 4, 6, 8, 10, and 12 (predose); day 14 (predose and 2,4, 6, 10, 24, 48 hours postdose); day 21; and day 28. To measure urinaryexcretion of API-MA, urine specimens were collected at the followingtimes: Day 1 (predose and 0 to 4, 4 to 8, 8 to 12, 12 to 24 hourspostdose) and day 14 (0 to 4, 4 to 8, 8 to 12, 12 to 24 hours postdose).

Mean [±SD] API-FB concentrations in plasma-time profiles for multiple SCadministration of API-MA at 0.5 and 1.0 mg/day for 14 days are depictedin FIG. 3. A summary of PK parameters on day 1 and day 14 at the twodoses is shown in Table 11 below. Cmax and AUCs were similar on day 1and 14, demonstrating no peptide accumulation. Cmax and AUC weredose-proportional.

TABLE 11 Summary of Mean (SD) PK Parameters on Days 1 and 14 0.5 1.0 Day1 Day 14 Day 1 Day 14 N 3 3 3 3 Tmax (hr) 2.11 (0.0344) 2.08 (0.0165)2.11 (0.0510) 2.11 (0.0587) Cmax (pg/mL) 8120 (1420) 8130 (1710) 16000(1210) 15500 (503) λz (1/hr) 0.200 (0.0160) 0.198 (0.00349) 0.221(0.0187) 0.205 (0.0103) T1/2 (hr) 3.48 (0.290) 3.50 (0.0614) 3.15(0.260) 3.38 (0.164) AUC (0-tau) (hr · pg/mL) 36500 (7740) 39100 (8050)70200 (5840) 71200 (5650) CL/F (L/hr) 13.4 (3.27) 12.6 (2.86) 13.6(1.10) 13.4 (1.10) Vz/F (L) 66.9 (13.3) 63.5 (13.2) 61.6 (6.32) 65.7(7.83) AUC (0-inf) (hr · pg/mL) 36800 (7860) NA 70600 (5990) NA MRT (hr)4.78 (0.522) NA 4.64 (0.405) NA AI (AUC) NA 1.07 (0.0659) NA 1.01(0.112) AI (T1/2) NA 1.01 (0.0678) NA 1.07 (0.0429) R (AUC) NA 1.07(0.0676) NA 1.02 (0.111) R (Cmax) NA 1.00 (0.0916) NA 0.967 (0.0502) Allparameter and summary statistics are presented to three significantfigures. λz = apparent elimination rate constant, AI = accumulationindex, AUC (0-tau) = area under the plasma concentration-time curve from0 to tau (24 hours), MRT = mean residence time from time 0 to infinity,NA = not applicable, R = cumulative ratio, Vz/F = apparent volume ofdistribution. Note: R (AUC) is calculated as AUC (0-tau) (Day 14)/AUC(0-tau) (Day 1). Note: AI (AUC) is calculated as AUC (0-tau) (Day14)/AUC (0-inf) (Day 1).

After SC administration of API-MA at 0.5 mg/day, as well as 1.0 mg/day,for 14 days, C_(max) was observed immediately after the end of 2-hourinfusion on Days 1 and 14 and then declined, with a mean T_(1/2) valueof about 3 to 4 hours on both days 1 and 14 at both doses. At 0.5mg/day, the mean CL/F values were 13.4 and 12.6 L/hr on days 1 and 14,respectively, and at 1.0 mg/day were 13.6 and 13.4 L/hr on days 1 and14, respectively, indicating apparent clearance of API-FB was almost thesame for both doses. The Vz/F of API-FB was also similar at both doselevels. The estimated accumulation index (AI) calculated using the ratioof AUC_((0-tau)) after multiple dosing/AUC_((0-inf)) after the singledose, and R calculated as the ratio of AUC_((0-tau)) after multipledosing/AUC_((0-tau)) after the single dose, were both approximately 1,indicating time independent PK of API-FB with minimal or no drugaccumulation after 2-hr SC infusion of 0.5 and 1 mg doses daily for 14days.

After SC administration of API-MA at 0.5 or 1.0 mg/day for 14 days, theurinary excretion of API-FB was almost complete by 8 hours postdose ondays 1 and 14. The mean percent cumulative excretion at 24 hourspostdose was 6.50% on day 1 and 8.99% on day 14 for the 0.5 mg/day dose,8.86% on day 1 and 9.41% on day 14 for the 1.0 mg/day dose,respectively. These findings suggest that renal excretion does notconsiderably contribute to clearance of API-FB.

Example 7: 1-Month Depot Pharmacokinetics of API-MA

Another study enrolled prostate cancer patients who had completed theirprimary treatment for prostate cancer at least 6 months prior toscreening and were either on GnRH therapy or were potential futurecandidates for GnRH therapy. Nine patients were enrolled, three in eachdose group (6, 12, and 24 mg). All were white men. Patients receivedAPI-MA as a single 1-month depot SC injection into the abdomen that wasintended to initiate both a high-burst release of API-MA and rapidstimulation of hypothalamic-pituitary-gonadal-axis, and was expected tosuppress testosterone. Overall, 4 of 9 patients received concomitantGnRH therapy. To measure plasma concentrations of API-MA, bloodspecimens were collected predose and at the following nominal times post1-month depot injection: Month 1 (0.25, 0.5, 0.75, 1, 2, 4, 6 and 12hours, and days 2, 3, 5, 8, 15, 22 and 29), month 2 (days 8, 15, 22 and29), and month 3.

FIGS. 4 and 5 show mean plasma concentration-time curves by dose groupfor the day 1 (up to 12 hours) and the full profile (up to month 3). Ahigh-burst release of API-MA drug concentrations was observed withinhours after administration of the depot injection. The AUC₍₀₋₂₄₎comprised over 60% of the AUC_((0-tlqc)) observed, showing a significantrelease of drug from formulation during the burst phase. Drugconcentrations were very low over the next several days followed by aslow rise, suggesting delayed and slow release from the formulation, aswell as onset of desensitization following continuous API-MA input. Inall cases, API-MA was not detectable by 8 weeks postdose.

Table 12 presents descriptive statistics by dose group, including the PKparameters of C_(max), T_(max), AUC₍₀₋₂₄₎, area under the plasmaconcentration-time curve from Day 0 to Day 29 of Month 1(AUC_((0-29d))), AUC_((0-tlqc)), and time to last quantifiableconcentration (Tlqc). The mean values representing the drug exposuregenerally increased slightly less than proportional to dose.

TABLE 12 Summary of PK Parameters Post Depot Injection Geometric Mean (%CV) 6 mg/month 12 mg/month 24 mg/month Parameter (N = 3) (N = 3) (N = 3)Cmax (pg/mL) 16541.7 (45.3) 14408.6 (41.7) 25518.0 (17.5) Tmax (hr) (a)2.000 (1.03, 2.12) 2.050 (1.02, 4.07) 2.050 (2.00, 4.00) AUC (0-24) (day· pg/mL) 3316.6 (28.7) 4979.1 (23.4) 7466.3 (31.9) AUC (0-29 d) (day ·pg/mL) 4328.8 (33.1) 5753.2 (30.9) 8701.2 (42.1) AUC (0-tlqc) (day ·pg/mL) 4947.6 (39.0) 6582.9 (43.7) 9948.6 (54.4) Tlqc (hr) 42.9 (16.2)41.5 (44.6) 47.2 (21.1) (a) Median (range)

Overall, the low plasma concentrations of API-MA, the delayed releaseprofile over the 1 month following administration, and the highinter-patient variability of the 1-month depot formulation wereconsidered not acceptable for further clinical development in prostatecancer patients. Furthermore, these results are not applicable to thedosing strategy that will be utilized for patients with hypothalamichypogonadism, since it is desired to stimulate thehypothalamic-pituitary-gonadal-axis without causing suppression oftestosterone.

Pharmacodynamics Single Dose Pharmacodynamics Summary:

Following single dose administration of API-MA to 37 Japanese men, therewas an increase in serum LH and FSH concentrations. LH and FSHconcentrations peaked between 12 and 24 hours and returned to baselineby 72 hours. The magnitudes of the hormone concentration increases weresimilar across the dose range, 0.001 to 0.5 mg. In a single dose phase 1study of API-MA conducted in 82 European men, administration of API-MAresulted in increased serum LH and FSH concentrations, which peakedbetween 6 and 12 hours and returned to baseline by 72 hours. Themagnitudes and durations of the hormone concentration increases weresimilar across the dose range, 0.001 to 6 mg.

Multiple-Dose Pharmacodynamics Summary:

In the two multi-dose studies, all doses used resulted in eventualsuppression of LH levels, as expected. In study C18001, 30 healthyEuropean men received single SC injection of 0.1 mg followed by aprolonged (continuous over 13 days) SC infusion of API-MA at doses of0.01, 0.1, 0.3, and 1.0 mg/day. Concentrations of gonadotropins peakedat 24 hours after the 0.1 mg bolus on day 1, consistent with the othersingle dose, phase 1 studies. During the prolonged infusion of API-MA,serum LH and FSH concentrations declined to values below baseline andreturned to baseline values within 7 days postdose. For most subjects,serum LH concentrations declined to low values. All of the subjects inthe 0.1 and 0.3 mg/day cohorts had LH concentrations below the lowerlimit of normal for a substantial portion of time during the SCinfusion. API-MA decreased serum LH and FSH levels after transientelevation, and this inhibition was maintained during the administration.Serum PSA levels decreased after API-MA administration, more profoundlyin patients receiving API-MA 1.0 mg/day.

Single Dose Pharmacodynamic Effects of API-MA:

In the phase 1 clinical study of API-MA, subjects enrolled in the firstseven cohorts received single SC bolus doses of 0.001, 0.004, 0.01,0.04, 0.1, 0.25 or 0.5 mg of API-MA or placebo. Subjects enrolled in theeighth and ninth cohorts received single SC infusion doses of 0.25 or0.5 mg of API-MA or placebo. The pharmacodynamics of the followinghormones were assessed: LH, FSH, dihydroepiandrosterone sulfate(DHEA-S), growth hormone (GH), prolactin (PRL), thyroid-stimulatinghormone (TSH), and adrenocorticotropic hormone (ACTH). Thepharmacodynamic analysis set consisted of 37 subjects (bolus cohorts:29; infusion cohorts: 8). To measure serum concentrations of thehormones in subjects in both the bolus and infusion cohorts, bloodspecimens were collected at the following nominal times: predose and 2,4, 6, 8, 12, 24, 48, 72 and 312 hours postdose. In addition, bloodspecimens were collected for the measurement of LH and FSH on the dayprior to dosing with API-MA. The time courses of mean serum LHconcentrations following a single SC bolus of API-MA at doses rangingfrom 0.001 mg to 0.5 mg are shown in FIG. 6. The LH concentrationspeaked between 12 and 24 hours and generally returned to baseline by 72hours postdose. The magnitudes and durations of the LH concentrationincreases were similar across the dose range, 0.001 to 0.5 mg. The LHtime courses were similar following a single 2-hour SC infusion ofAPI-MA (data not shown).

As shown in FIG. 7, the serum FSH concentrations increased after asingle SC bolus dose of API-MA compared with placebo. The elevation ofFSH peaked within 24 hours and generally returned to the predose levelby 72 hours after the injection. The magnitudes and durations of the LHand FSH concentration increases were similar across the dose range,0.001 to 0.5 mg. The LH and FSH time courses were similar following asingle 2-hour SC infusion of API-MA (data not shown).

Another study was a single dose, phase 1 clinical study of API-MA inhealthy men age 50 to 76 years. Subjects enrolled in the first sevencohorts received 0.001, 0.003, 0.01, 0.03, 0.1 or 0.3 mg of API-MA orplacebo by single SC bolus. Subjects enrolled in the seventh, eighth,and ninth cohorts received 1, 3, or 6 mg of API-MA or placebo by single2-hour SC infusion. The pharmacodynamics of each of the followinghormones was assessed: LH and FSH. PRL, TSH, cortisol, sex hormonebinding globulin (SHBG), and plasma ACTH (also known as corticotropin)concentrations were measured on the day prior to dosing and on day 4,the Final Visit. To measure serum concentrations of LH and FSH in thebolus cohorts, blood specimens were collected at the following nominaltimes: the day prior to dosing, predose, and 0.083, 0.25, 0.75, 1, 2, 3,4, 6, 8, 12, 16, 24, 36, 48 and 72 hours postdose. In the infusioncohorts, blood specimens were collected at the following nominal times:the day prior to dosing, predose or start of the infusion, and 0.5, 1,1.5, 2 (end of infusion), 2.25, 2.5, 3, 4, 6, 8, 10, 14, 18, 26, 50 and74 hours after the start of infusion. Serum LH concentrations over timeare shown in FIG. 8. Serum LH concentrations increased after a single SCbolus of API-MA, as well as after a single 2-hour SC infusion of API-MA.The concentrations peaked between 6 and 12 hours and returned tobaseline by 72 hours. The magnitudes and durations of the LHconcentration increases were similar across the dose range, 0.001 to 6mg.

API-MA administration generally resulted in an initial, moderateincrease in mean FSH concentrations at all dose levels, followed by adecline towards baseline levels by 72 hours as shown in FIG. 9. Theseincreases were not dose dependent. Peak values were generally reached atapproximately 12 hours with all dose levels. There were no relevantchanges in the serum concentrations of SHBG, prolactin, TSH,corticotropin, or cortisol following administration of API-MA at anydose level.

Example 8: Multiple-Dose Pharmacodynamic Effects of API-MA

This study was a phase 1 study of multiple-day, continuous SC infusionsof API-MA to 30 healthy European men over age 50. Subjects enrolled intothe four cohorts received a single SC bolus of API-MA 0.1 mg or placebo(day 1) followed by 0.01, 0.1, 0.3, or 1.0 mg/day of API-MA or placeboby continuous SC infusion over 13 days (days 2 to 14). Five to six menreceived active API-MA, and 1 to 2 men received placebo per dose levelcohort. The pharmacodynamics of the following hormones were assessed: LHand FSH.

To measure serum concentrations of LH and FSH, blood specimens werecollected on the day prior to dosing with API-MA at the followingnominal times: −24, −16, and −12 hours (prior) to SC bolus dosing,immediately prior to the SC bolus dose, and 6, 12, 24, 30, 36, 48, 78,84, 96, 174, 180, 192, 246, 252, 264, 318, 324 and 336 hours post-bolusdose. The SC infusion was started 24 hours after the bolus injection;all specimens collected after the 24-hour time point were collectedduring the SC infusion. Blood specimens were also collected on days 16,17, 21, 28 and 44 to monitor the return of the hormone concentrations tobaseline values.

As shown in FIGS. 10 and 11, in all active treatment groups, mean serumconcentrations of LH and FSH increased following the 0.1 mg SC bolus ofAPI-MA on day 1. During the 13-day SC infusion of API-MA, mean serum LHand FSH concentrations declined to values below baseline and returned tonear baseline values within 7 days postdose. For most subjects, serum LHconcentrations declined to low values. All of the subjects in the 0.1and 0.3 mg/day cohorts had LH concentrations below the lower limit ofnormal for most of the SC infusion treatment period. Conversely, insubjects in the placebo treatment group, mean serum concentrations of LHand FSH remained within normal range throughout the study.

The study was a phase 1 study in hormone naïve Japanese prostate cancerpatients. Six patients received API-MA doses of 0.5 mg (3 patients) and1.0 mg (3 patients) administered via 2-hour SC infusion once daily for14 days. Summary statistics of serum concentrations of LH, FSH, GH, PRL,and TSH, as well as plasma concentration of ACTH and serum concentrationof prostate-specific antigen (PSA), at baseline and at each evaluationpoint, changes from baseline were calculated for each dose, and the data(individual values and mean±standard deviation) were plotted againsttime for each dose. Serum LH profiles are displayed in FIG. 12 for theAPI-MA 0.5 mg/day dose group. Serum LH levels sharply increased at day2, and returned to the baseline level by day 4. These levels werecompletely suppressed from Day 6 to Day 16, and returned to the baselinelevel by a week after the last dose. Changes in serum LH were similarbetween 0.5 and 1.0 mg of API-MA (data for API-MA 1.0 mg/day dose groupnot shown).

Serum FSH profiles are displayed in FIG. 13 for the API-MA 0.5 mg/daydose group. Serum FSH levels also sharply increased at day 2, andreturned to the baseline level by day 4. These levels were completelysuppressed from Day 6 to Day 16, and returned to the baseline level by aweek after the last dose. Changes in serum FSH were similar between 0.5and 1.0 mg of API-MA (data for API-MA 1.0 mg/day dose group not shown).

Serum PSA levels decreased after administration of API-MA and the lowPSA levels were maintained until a week after the last dose in allsubjects. Serum PSA levels decreased approximately 40% compared to thebaseline level in patients receiving 0.5 mg of API-MA, and a moreprofound approximately 50% to 60% decline occurred in patients receiving1.0 mg of API-MA.

Example 9: 1-Month Depot Effects of API-MA

Nine patients with prostate cancer were enrolled in another study, threein each dose group (6, 12, and 24 mg). Patients received API-MA as asingle 1-month depot injection that was intended to initiate both ahigh-burst release of API-MA and rapid stimulation ofhypothalamic-pituitary-gonadal axis. Overall, 4 of 9 patients receivedconcomitant GnRH therapy. Assessments of pharmacodynamics included LHconcentrations and serum PSA concentrations. Results were grouped basedon patients who were or were not receiving concomitant GnRH therapy.

LH reductions corresponding to changes in testosterone were observed inGnRH-naïve patients. Post screening serum LH concentrations ranged from0.1 to 0.5 mIU/mL in the 6 mg dose group, from <0.1 to 7.9 mIU/mL in the12 mg dose group, and from 0.3 to 9.8 mIU/mL in the 24 mg dose group,with individual variation between patients throughout the follow-upperiod. Two out of nine patients receiving concomitant GnRH analogtherapy (one in the 6 mg and one in the 12 mg dose group) had PSAconcentrations <0.01 ng/mL with no detectable percent changes frombaseline for all but one measurement throughout the study. In theremaining seven patients, the greatest percent decrease from baseline inPSA was seen at month 1, day 29 (8% and 19% for patients in the 6 mgdose group, 25% and 62% for patients in the 12 mg dose group, and 74%,79%, and 88% for patients in the 24 mg dose group). A further decreasein percent change from baseline was seen for three patients (one in the6 mg, one in the 12 mg, and one in the 24 mg dose group) at month 2 day29, with the greatest reduction in PSA of 91% observed in a patient inthe 24 mg dose group.

Example 10: Use of Compound 1 and Relugolix in ART

In an effort to improve both the safety and efficacy outcomes in ART,such as IVF, and/or in an ET process, key modifications to some of thekey steps of that process are herein noted and involve the use ofCompound 1 and relugolix.

Traditional IVF protocols begin with an initial phase known as COS. Inthis phase, on day 2 or 3 of a patient's menses, FSH is administered topromote the growth and development of follicles, and is continued untilovulation occurs (˜Day 14). Approximately 3-5 days after FSH isinitiated, either a GnRH agonist or more commonly now, a GnRH antagonistis added to the regimen to prevent premature ovulation (the release ofpremature follicles due to a LH surge), and like FSH is continued untilovulation occurs. A common GnRH antagonist used in these protocols todayis injectable cetrorelix, but in this particular prophetic example, anoral GnRH antagonist, relugolix, is used, as it reduces the number ofmultiple injections in ART, such as IVF and/or in an ET process, and mayallow a more tailored titration of GnRH antagonist activity compared toan injectable. Improving the residual GnRH antagonist activity mayimprove the LH response to the trigger (Compound 1 described below),which ultimately improves the implantation rate. Relugolix can suppressand prevent premature ovulation, allowing eggs to mature and later beretrieved from the ovaries (instead of the fallopian tubes). Relugolixmay also prevent high-order multiple gestation that can result fromexposure of eggs to sperm in the fallopian tube if intercourse hasoccurred. Together, this stimulation process with FSH and a GnRHantagonist, Relugolix is called COS.

Once the follicles have progressed to a pre-defined state, in which thelead follicle is measured as >14 mm, a so-called “trigger” agent is usedto promote the final maturation, release and retrieval of eggs from theovary in preparation for IVF and ET to the uterus. Compound 1(2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or apharmaceutically acceptable salt thereof, and a pharmaceuticallyacceptable excipient) is used as the trigger agent. Compound 1 is usedas a trigger to promote oocyte maturation and induce ovulation forsubsequent retrieval, fertilization (in vitro) and ET. Other agents(e.g., estradiol and progestins) are also used to support the uterus(endometrium), so-called luteal phase support in preparation forimplantation.

One of the main risk associated with ART, including IVF and/or in an ETprocess, is the development of OHSS. While some patients are at higherrisk of development OHSS, the use of hCG-based trigger agents (i.e., hCGalone or hCG with a GnRH agonist) is known to increase the risk of OHSS.Compound 1, is expected to significantly decrease the risk of OHSS.

When Compound 1 is used as a trigger agent, it is expected to providesimilar or improved pregnancy rates compared to hCG-based or GnRHagonist trigger agents. Compound 1 facilitates the maturation, release(ovulation) and retrieval of fresh mature oocytes (eggs) from theovaries, leading to higher pregnancy rates, while significantlymitigating the risk of key side effects, like OHSS.

The use of hCG-based trigger agents is known to increase the need forsegmentation freeze protocols that delay embryo transfer. Due to the MOAof Compound 1, there is less negative impact on the endometrium comparedto current treatments. Thus, the endometrium is ready for implantation(higher endometrial receptivity) immediately after egg retrieval, thusreducing the need for segmentation (freezing the egg or embryo betweenretrieval and implantation). After retrieval, the egg is fertilized withsperm, and the fresh embryo is implanted into the endometrium andpregnancy ensues. Compound 1 results in less need for a segmentationfreezing protocol, thereby reducing the number of IVF cycles andshortening the time to pregnancy, while maintaining acceptable pregnancyrates, with significantly lower OHSS rates.

Example 11: Investigation of the Physiological Effects of Compound 1 inWomen

Part 1: Identify the Dosing Range of Compound 1

Kisspeptin-54 has previously been shown to be clinically effective as atrigger for oocyte maturation in IVF studies. This study analyzed dosesof Compound 1, administered during the early follicular phase of themenstrual cycle to enable identification of doses that can stimulate aLH-response, and compare similarities and differences to the LH-responseof kisspeptin-54.

The study population included healthy women, aged 18-35 years, with BMI18-30 kg/m², no medical problems and not taking any medications orhormonal contraception. Three healthy, female subjects were selected andrandomized and received a single dose of each of the three studyregimens noted below (one regimen per study period). All women werescheduled for three Study D1 Visits (each during the follicular phase ofthe menstrual cycle). Each subject received a single dose of one of thefollowing three study regimens on the Study D1 Visit during each studyperiod (three study periods in total), such that at the end of this partof the study, each subject received all three of the following studyregimens (one per study period):

-   -   Kisspeptin-54 (KP54), 9.6 nmol/kg    -   Compound 1, 0.003 nmol/kg* or 0.00368 mcg/kg    -   Compound 1, 0.03 nmol/kg* or 0.0368 mcg/kg * For example, a 60        kg woman who is administered the 0.003 nmol/kg dose of Compound        1, would receive 0.18 nmols or 0.221 mcg. The order in which a        subject receives one of the three study regimens was determined        by a randomization matrix.

Compound 1 vials were stored at 4° C. and consisted of 200 mcg (0.2 mg)in 2000 mcl (2 mL), i.e., 0.1 mcg/mcl (0.1 mg/mL). Freeze-driedkisspeptin-54 (600 nmol per vial) was reconstituted in 0.5-1 mL ofnormal saline in preparation for subcutaneous injection (Table 13).

TABLE 13 Compound 1 SC Formulation Quantity per Component Function Vial(2 mL) Compound 1 drug substance API 0.21 mg Compound 1 Freebase (0.2mg) D-Mannitol, JP/USP/Ph.Eur. Tonicity agent 100 mg Glacial aceticacid, pH adjusting agent Appropriate amount JP/USP/Ph.Eur. Water forinjection, Solvent q.s. to 2 mL JP/USP/Ph.Eur.

The study included a screening visit to collect participants' fullmedical history and to conduct a general medical examination and bloodtesting. The three study periods each consisted of three planned studyvisits per study period (excluding screening and follow-up). Study Day 1(SD1) Visit of each study period occurred during the follicular phase ofthe menstrual cycle (days 1-4), and the SD2 and SD3 Visits occurred at24- and 48-hrs post-dose, respectively (FIG. 14). A follow-up phone callhappened 7-10 days post-dose in each study period.

On Study Day 1, following confirmation of a negative urine pregnancytest, a single dose (via subcutaneous injection on the abdomen) ofeither Compound 1 (0.003 nmol/kg, or 0.03 nmol/kg) or Kisspeptin-54 (9.6nmol/kg) was administered at time zero.

Immediately following dosing, serum LH, FSH, E2 (oestradiol), P(progesterone) and SHBG levels were assessed at 30 minute intervals forup to 14 hours (FIGS. 15A-15C, 16A-16C, 17, 18, 19, 20A, and 20B). ThesePD variables were also assessed at 24 (Study Day 2) and 48 hours (StudyDay 3) post-dose. SHBG changes less rapidly and was measured every 3hours to reduce blood volume.

Up to 3 mL of blood volume were required for measurement of serumreproductive hormone levels (LH, FSH, E2 and P). Blood samples for serumanalysis were collected in plain Vacutainer tubes (Beckton Dickson,Franklin Lakes, N.J., USA), and spun after clotting (˜1 hour at roomtemperature) for 10 minutes at 3000 rpm. Serum was then stored in alocked freezer at −20° C. until assay of serum reproductive hormonelevels.

Plasma levels of Compound 1 and kisspeptin-54 were assessed for thefirst 6 hours to minimize withdrawal of excess blood volumes.

As shown in FIGS. 15A and 16A, subjects receiving kisspeptin-54 showedan increase in LH peaking around 4-6 hours after kisspeptin-54administration, with the LH surge lasting approximately 14 hours.Subjects receiving 0.003 nmol/kg Compound 1 (FIGS. 15C and 16B) and 0.03nmol/kg Compound 1 (FIGS. 15B and 16C) also showed an increase in LHafter Compound 1 administration, however, peak LH levels were achievedmuch later than observed with kisspeptin-54 administration and the LHsurge lasted much longer (FIGS. 17-19). After administration of the0.003 nmol/kg Compound 1 dose, peak serum LH levels were observedbetween 14-36 hours post-dosing and the LH surge lasted approximately 48hours. With the 0.03 nmol/kg Compound 1 dose, following an initial LHdecrease, peak serum LH levels were observed between 18-20 hours afteradministration and the LH surge lasted approximately 14 hours, ending 28hours after administration. A longer LH surge is preferable in IVF topromote oocyte maturation. Further, observation of a long LH surgeduring the early follicular phase was unexpected, particularly as thekisspeptin-54 LH surge lasted only 14 hours compared to theapproximately 48 hour surge observed with the 0.003 nmol/kg Compound 1dose.

The small increases in E2 after Compound 1 administration were similarto those observed with kisspeptin-54 and are supportive of a similarmechanism of action in stimulating release of gonadotropins and sexhormones (FIG. 20B). Surprisingly, the FSH response was very lowcompared to the LH response, which is very different to the resultsobserved in men where robust responses in both LH and FSH were evident(FIG. 20A and Example 7, FIGS. 8 and 9). Additionally, there was somepotential desensitization of FSH response at the 24 and 48 hour timepoints, also not evident in men (FIGS. 9 and 20A).

The 0.003 nmol/kg dose of Compound 1 only had two subjects' results asthe third subject attended on what was believed to be day 4 of cyclefollowing light menstrual bleeding (FIG. 16B). Her actual period arriveda few days later, and a serum progesterone level confirmed that she hadactually been in the Luteal Phase of the previous cycle (day 36) duringthe study visit.

Part 2: Randomized, Open-Label, Cross-Over Study to Investigate theEffects of Compound 1 in Healthy Women

In this part of the study, the objective is to identify doses ofCompound 1 (administered during the follicular phase of the menstrualcycle) that provide the most optimal safety, tolerability and PD profile(namely LH response) in healthy women. Low, intermediate and high doseof Compound 1 that spans the dose range of Compound 1 identified in Part1 will be compared with a dose of kisspeptin-54 (9.6 nmol/kg) known tobe effective in triggering oocyte maturation during IVF treatment inprevious studies, again aiming for an approximate 10-20% increase inpeak LH response when compared to the kisspeptin-54 dose. This willallow the rapid identification of a dose of Compound 1 that mightsubsequently be used as a trigger agent in IVF therapy. A subcutaneousdose of a GnRH agonist (triptorelin 0.2 mg), currently used to triggeroocyte maturation during IVF therapy, will also be used to provide acomparison for Compound 1.

As noted previously, in Part 1 of this study, Compound 1 wasadministered during the follicular phase of the menstrual cycle, whilethe present phase occurs in a COS setting as part of ART prior to IVF.Thus, the amplitude of the LH surge is expected to differ from theamplitude of the LH surge observed when Compound 1 was administeredduring the follicular phase.

The study population will include 8 healthy women, aged 18-35 years,with BMI 18-30 kg/m², no medical problems and not taking any medicationsor hormonal contraception. The screening visit for this study willcollect the same information detailed in Part 1.

This part of the study will consist of six study periods. A Follow-upVisit will occur within 7-10 days post-dose in each study period. Eightsubjects will be randomized to receive a single dose of each of the 6study regimens (one regimen per study period). All women will bescheduled for 6 Study Day 1 Visits (each during the follicular phase ofthe menstrual cycle). Each subject will receive a single dose of one ofthe following 6 study regimens on the Study Day 1 Visit during eachstudy period, such that at the end of this part of the study, eachsubject will have received all 6 study regimens (one per study period):

-   -   Normal Saline (0.9%) 100 μL    -   Compound 1 LOW dose, e.g., 0.003 nmol/kg* or 0.00368 mcg/kg (or        alternate LOW dose confirmed following part 1)    -   Compound 1 INTERMEDIATE dose, e.g., 0.01 nmol/kg* or 0.0123        mcg/kg (or alternate INTERMEDIATE dose confirmed following part        1)    -   Compound 1 HIGH dose, e.g., 0.03 nmol/kg* or 0.0368 mcg/kg (or        alternate HIGH dose confirmed following part 1)    -   Kisspeptin-54 9.6 nmol/kg    -   GnRH agonist (triptorelin 0.2 mg SC) * For example, a 60 kg        woman who is administered the 0.003 nmol/kg dose of Compound 1,        would receive 0.18 nmols or 0.221 mcg. The order in which        individual women receive one of the six study regimens will be        determined by a randomization matrix.

On Study Day 1, following confirmation of a negative urine pregnancytest, a single dose (via subcutaneous injection on the abdomen) ofeither Compound 1 (LOW, e.g., 0.003 nmol/kg; INTERMEDIATE, e.g., 0.01nmol/kg; or HIGH, e.g., 0.03 nmol/kg), Kisspeptin-54 (9.6 nmol/kg), GnRHagonist (triptorelin 0.2 mg) or normal saline (0.9%, 100 μl), will beadministered at time zero.

Blood sampling, testing, drug storage, and dose preparation will occuras in Part 1.

Part 3: Randomized, Open-Label, Cross-Over Study to Evaluate the Effectsof Compound 1 in Women with Anovulatory PCOS

In this part of the study, the objective is to compare the PK/PD profile(in particular, LH and FSH response) of the optimal dose of Compound 1(identified in Part 2 in healthy women) with the PK/PD profile seen inwomen with anovulatory PCOS. Women will be diagnosed as anovulatory PCOSif oligomenorrheic (menstrual cycle length >35 days), increased serumAMH (>35 pmol/L) or antral follicle count on ultrasound >23, ±clinicalor hormonal evidence of hyperandrogenism. Based on previous studiesusing kisspeptin-54, a similar, but slightly higher LH response isexpected in women with PCOS compared to healthy women. The response to asingle dose of Compound 1 will also be compared to that of a GnRHagonist (triptorelin 0.2 mg), a therapy commonly used in women with PCOSto trigger oocyte maturation. This will allow comparison of the optimaldose of Compound 1 (previously identified in Part 2) with currentstandard therapy.

The study population will be women, aged 18-35 years, with anovulatoryPCOS.

The screening visit for this study will collect the same informationdetailed in Part 1, but will also have the following two additions: 1)Prior to SD1, women will be induced with Provera (administered as a 10mg BID for one week just prior to SD1). 2) Following the Provera-inducedrun-in, women will begin each study period, as was done in Part 1 and 2,beginning on day 1-4 of their Provera-induced menstrual cycle(follicular phase).

Eight subjects will be randomized to receive a single dose of each ofthe 4 study drug regimens (one regimen per study period) per therandomization matrix. All women will be scheduled for 4 Study Day 1Visits (each during the follicular phase of the menstrual cycle inconsecutive months). Each subject will receive a single dose of one ofthe following four (4) study regimens on the Study Day 1 Visit duringeach study period, such that at the end of this part of the study, eachsubject will have received all 4 of the following study regimens (oneper study period):

-   -   Normal Saline (0.9%) 100 μL    -   Compound 1*    -   KP54 9.6 nmol/kg SC    -   GnRH agonist (triptorelin 0.2 mg SC) *The Compound 1 dose will        be confirmed in Part 2 (healthy volunteer) of the study and the        duration of blood sampling for PD analysis following each study        regimen will be confirmed following part 1 of the study, e.g.,        the duration of blood sampling following Compound 1 may be        reduced from 14 hours to 8-12 hours, following kisspeptin-54 to        8-10 hours and following normal saline to 6-8 hours.

On Study Day 1, following confirmation of a negative urine pregnancytest, a single dose (via subcutaneous injection on the abdomen) of theoptimal Compound 1 dose (as determined in Part 2 of the study),Kisspeptin-54 (9.6 nmol/kg), GnRH agonist (0.2 mg triptorelin) or normalsaline (0.9%, 100 μl) will be administered at time zero.

Blood sampling, testing, drug storage, and dose preparation will occuras in Parts 1 and 2.

ENUMERATED EMBODIMENTS

Some embodiments of the disclosure relate to Embodiment I:

Embodiment I-1

A method for promoting egg maturation and inducing ovulation in assistedreproductive technologies (ART), such as IVF or in an embryo transfer(ET) process, the method comprising: administering to a female humansubject a therapeutically effective amount of about 0.001 mg to about600 mg of2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or acorresponding amount of a pharmaceutically acceptable salt thereof.

Embodiment I-2

The method of Embodiment I-1, wherein the pharmaceutically acceptablesalt is2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamidemonoacetate.

Embodiment I-3

The method of Embodiment I-1, wherein the therapeutically effectiveamount of about 0.001 mg to about 600 mg of2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or acorresponding amount of a pharmaceutically acceptable salt thereof isadministered via injection.

Embodiment I-4

The method of Embodiment I-1, wherein the therapeutically effectiveamount of about 0.001 mg to about 600 mg of2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or acorresponding amount of a pharmaceutically acceptable salt thereof isadministered in the form of a delayed release, single dose.

Embodiment I-5

The method of Embodiment I-1, wherein2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamideis represented by the formula:

Embodiment I-6

The method of Embodiment I-2, wherein the2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamidemonoacetate is represented by the formula:

Embodiment I-7

The method of Embodiment I-1, wherein the administration of2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or apharmaceutically acceptable salt thereof, triggers ovulation in thehuman female subject (i) without increasing levels of VEGF or (ii)increasing levels of VEGF for less than 24 hours.

Embodiment I-8

A method for promoting egg maturation in ART, such as IVF or in an ETprocess, the method comprising: administering to a female human subject,via injection, a therapeutically effective amount of about 0.001 mg toabout 5 mg of2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or acorresponding amount of a pharmaceutically acceptable salt thereof.

Embodiment I-9

The method of Embodiment I-8, wherein the pharmaceutically acceptablesalt thereof is2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamidemonoacetate.

Embodiment I-10

The method of Embodiment I-8, wherein the administration issubcutaneous.

Embodiment I-11

The method of Embodiment I-8, wherein the administration isintramuscular.

Embodiment I-12

The method of Embodiment I-8, wherein the administration is intravenous.

Embodiment I-13

The method of Embodiment I-8, wherein2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide isrepresented by the formula:

Embodiment I-14

The method of Embodiment I-8, wherein2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamidemonoacetate is represented by the formula:

Embodiment I-15

A method for promoting egg maturation in ART, such as IVF or in an ETprocess, the method comprising: administering to a female human subject,by intranasal route, a therapeutically effective amount of about 0.001mg to about 5 mg of2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or acorresponding amount of a pharmaceutically acceptable salt thereof.

Embodiment I-16

The method of Embodiment I-15, wherein the pharmaceutically acceptablesalt is2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamidemonoacetate.

Embodiment I-17

The method of Embodiment I-15, wherein2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide isrepresented by the formula:

Embodiment I-18

The method of Embodiment I-15, wherein2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamidemonoacetate is represented by the formula:

Embodiment I-19

A method for inducing ovulation in ART, such as IVF or in an ET process,the method comprising the following: administering to a human femalesubject one or more human gonadotropins, coupled with a GnRH agonist orantagonist (˜2-3 days later) to facilitate an initial COS phase andprevent premature ovulation in ART, such as IVF and/or an ET process,wherein the initial COS phase is followed by the administration of2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or apharmaceutically acceptable salt thereof, to effectively promotematuration of oocytes and induce ovulation (i) without increasing thetotal blood concentration level of VEGF or (ii) by increasing the totallevel of VEGF for less than 24 hours.

Embodiment I-20

The method of Embodiment I-19, wherein the pharmaceutically acceptablesalt thereof is2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamidemonoacetate.

Embodiment I-21

The method of Embodiment I-19, wherein2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or acorresponding amount of a pharmaceutically acceptable salt thereof, isadministered in an amount from about 0.001 mg to about 600 mg.

Embodiment I-22

The method of Embodiment I-19, wherein2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or acorresponding amount of a pharmaceutically acceptable salt thereof, isadministered via injection in an amount from about 0.001 mg to about 5mg.

Embodiment I-23

The method of Embodiment I-19, wherein2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or acorresponding amount of a pharmaceutically acceptable salt thereof, isadministered intranasally in an amount from about 0.001 mg to about 5mg.

Embodiment I-24

The method of Embodiment I-19, wherein the one or more humangonadotropins are administered orally or via injection and consist of afollicle stimulating hormone, a luteinizing hormone, or a combinationthereof.

Embodiment I-25

The method of Embodiment I-19, wherein if a GnRH agonist is used in theCOS phase in the same protocol as2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or apharmaceutically acceptable salt thereof, (as the trigger agent), theGnRH agonist is a combination of leuprorelin acetate, and if a GnRHantagonist is used in the COS phase in the same protocol as2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or apharmaceutically acceptable salt thereof, (as the trigger agent), theGnRH antagonist is selected from the group consisting of ganirelix,cetrorelix, relugolix, and pharmaceutically acceptable salts of any ofthe foregoing.

Embodiment I-26

The method of Embodiment I-19, wherein the GnRH agonist is selected fromthe group consisting of leuprorelin acetate, gonadorelin, buserelin,triptorelin, goserelin, nafarelin, histrelin, deslorelin, meterelin,lecirelin, and pharmaceutically acceptable salts of any of theforegoing.

Embodiment I-27

The method of Embodiment I-19, wherein the GnRH antagonist is relugolix,or a pharmaceutically acceptable salt thereof.

Embodiment I-28

The method of Embodiment I-19, wherein the GnRH antagonist is selectedfrom the group consisting of cetrorelix, ganirelix, abarelix, nal-blu,antide, azaline B, degarelix, D63153, relugolix, teverelix, andpharmaceutically acceptable salts of any of the foregoing.

Embodiment I-29

A method of reducing the rate of OHSS in ART, such as IVF or in an ETprocess, wherein2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or apharmaceutically acceptable salt thereof, is used as the trigger agentas compared to hCG-based trigger agents.

Embodiment I-30

A method of comparable or improved pregnancy rates in ART, such as IVFor in an ET process, wherein2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or apharmaceutically acceptable salt thereof, is used as the trigger agentas compared to GnRH agonist or hCG-based trigger agents.

Embodiment I-31

A method of shorter time to pregnancy in ART, such as IVF or in an ETprocess, wherein2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or apharmaceutically acceptable salt thereof, is used as the trigger agentas compared to hCG-based trigger agents.

Embodiment I-32

A method for inducing ovulation in an anovulatory, human female subjectsuffering from secondary ovarian failure, comprising the steps of (1)pretreating the subject with one or more human gonadotropins and (2)administering to the subject a therapeutically effective amount of2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or apharmaceutically acceptable salt thereof.

Embodiment I-33

A method of preventing premature ovulation during the COS phase of ART,such as IVF and/or in an ET process, wherein relugolix, or apharmaceutically acceptable salt thereof, is used as compared to the useof a GnRH agonist in the COS phase.

Some embodiments of the disclosure relate to Embodiment II:

Embodiment II-1

A method of elevating endogenous LH level in a woman in need thereof,the method comprising: administering to the woman an initial dose ofabout 0.00003 mg to about 0.030 mg of2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or acorresponding amount of a pharmaceutically acceptable salt thereof,wherein the woman is undergoing ART and is at risk for OHSS, and whereinafter the initial dose is administered, the woman's endogenous LH levelin blood is elevated compared to the woman's endogenous LH level inblood prior to administration of the initial dose.

Embodiment II-2

A method of increasing endogenous LH level in a woman in need thereofundergoing ART, the method comprising: administering to the woman aninitial dose of about 0.00003 mg to about 0.030 mg of2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or acorresponding amount of a pharmaceutically acceptable salt thereof,wherein the woman is undergoing ART, and wherein at least 36 hours afterthe initial dose is administered, the woman's endogenous LH level inblood is elevated compared to the woman's endogenous LH level in bloodprior to administration of the initial dose.

Embodiment II-3

A method of increasing endogenous LH level in a woman in need thereofundergoing ART, the method comprising: administering to the woman aninitial dose of about 0.00003 mg to about 0.030 mg of2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or acorresponding amount of a pharmaceutically acceptable salt thereof,wherein the woman is undergoing ART, and wherein the maximum endogenousLH level in blood occurs at least about 12 hours after administration ofthe initial dose.

Embodiment II-4

The method of Embodiment II-3, wherein the maximum endogenous LH levelin blood occurs between about 12 hours and about 48 hours afteradministration of the initial dose.

Embodiment II-5

A method of increasing endogenous LH level in a woman undergoing ART andin need of luteal phase support, the method comprising: administering tothe woman an initial dose of about 0.00003 mg to about 0.030 mg of2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or acorresponding amount of a pharmaceutically acceptable salt thereof,after said woman has received a trigger dose of an oocyte maturationagent as part of an ART regimen.

Embodiment II-6

The method of any one of the preceding Embodiments, wherein the woman'sendogenous LH level in blood is elevated between about 12 hours to about96 hours after administration of the initial dose compared to thewoman's endogenous LH level in blood prior to administration of theinitial dose.

Embodiment II-7

The method of any one of the preceding Embodiments, wherein the woman'sendogenous LH level in blood is elevated for at least 36 hours afteradministration of the initial dose compared to the woman's endogenous LHlevel in blood prior to administration of the initial dose.

Embodiment II-8

The method of Embodiment II-7, wherein the endogenous LH level in bloodis elevated for about 36 hours to about 16 days.

Embodiment II-9

The method of Embodiment II-7, wherein the endogenous LH level in bloodis elevated for about 36 hours to about 12 days.

Embodiment II-10

The method of any one of the preceding Embodiments, wherein theadministration of the initial dose promotes oocyte maturation.

Embodiment II-11

The method of Embodiment II-10, wherein oocyte maturation occurs withoutthe administration of exogenous hCG or exogenous LH.

Embodiment II-12

The method of Embodiment II-10 or II-11, wherein oocyte maturationoccurs after administration of a GnRH agonist.

Embodiment II-13

The method of Embodiment II-10, wherein oocyte maturation occurs afteradministration of exogenous hCG.

Embodiment II-14

The method of any one of Embodiments II-10 to II-13, wherein the yieldof mature oocytes is at least 50%.

Embodiment II-15

The method of any one of the preceding Embodiments, wherein afteradministration of the initial dose, the woman does not experience one ormore symptoms selected from the group consisting of ascites, pleuraleffusion and reduced renal perfusion.

Embodiment II-16

The method of any one of the preceding Embodiments, wherein afteradministration of the initial dose, ovary size may not increase togreater than 5 cm in diameter.

Embodiment II-17

The method of any one of the preceding Embodiments, wherein the womandoes not experience one or more symptoms of OHSS after administration ofthe initial dose.

Embodiment II-18

The method of any one of Embodiments II-1 to II-16, wherein afteradministration of the initial dose, the woman does not experience aworsening of one or more symptoms of OHSS.

Embodiment II-19

The method of any one of the preceding Embodiments, wherein the initialdose is administered when at least three ovarian follicles of at least14 mm are visible via ultrasound.

Embodiment II-20

The method of any one of the preceding Embodiments, wherein the initialdose is administered when at least three ovarian follicles of at least18 mm are visible via ultrasound.

Embodiment II-21

The method of any one of the preceding Embodiments, wherein the initialdose is administered when serum estradiol concentration is at least 0.49nmol/L.

Embodiment II-22

The method of any one of the preceding Embodiments, wherein the methodfurther comprises administration of FSH about 5 days to about 12 daysprior to administration of the initial dose.

Embodiment II-23

The method of any one of the preceding Embodiments, wherein the methodfurther comprises administration of a GnRH antagonist about 2 days toabout 10 days prior to administration of the initial dose.

Embodiment II-24

The method of Embodiment II-23, wherein the GnRH antagonist is selectedfrom the group consisting of relugolix, elagolix, cetrorelix, ganirelix,abarelix, nal-blu, antide, azaline B, degarelix, D63153 (ozarelix),OBE2109, and teverelix.

Embodiment II-25

The method of any one of Embodiment II-1 to II-24, wherein the methodfurther comprises administration of a GnRH agonist from about 14 toabout 28 days prior to administration of the initial dose.

Embodiment II-26

The method of Embodiment II-25, wherein the GnRH agonist is selectedfrom the group consisting of leuprorelin acetate, gonadorelin,buserelin, triptorelin, goserelin, nafarelin, histrelin, deslorelin,meterelin, and lecirelin.

Embodiment II-27

The method of any one of the preceding Embodiments, wherein the initialdose is administered prior to oocyte retrieval.

Embodiment II-28

The method of any one of Embodiments II-1 to II-27, wherein the initialdose is administered after oocyte retrieval.

Embodiment II-29

The method of any one of Embodiments II-1 to II-27, wherein the initialdose is administered prior to ovulation.

Embodiment II-30

The method of any one of Embodiments II-1 to II-27, wherein the initialdose is administered after ovulation.

Embodiment II-31

The method of any one of the preceding Embodiments, wherein the initialdose is administered after administration of a GnRH agonist as an oocytematuration agent.

Embodiment II-32

The method of Embodiment II-31, wherein the GnRH agonist is selectedfrom the group consisting of leuprorelin acetate, gonadorelin,buserelin, triptorelin, goserelin, nafarelin, histrelin, deslorelin,meterelin, and lecirelin.

Embodiment II-33

The method of any one of the preceding Embodiments, wherein the methodfurther comprises administering a second dose of about 0.00003 mg toabout 0.030 mg of2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or acorresponding amount of a pharmaceutically acceptable salt thereof.

Embodiment II-34

The method of Embodiment II-33, wherein the second dose is administeredwithin about 8 to about 60 hours after administration of the initialdose.

Embodiment II-35

The method of Embodiment II-33 or II-34, wherein the method furthercomprises administering a third dose of about 0.00003 mg to about 0.030mg of2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or acorresponding amount of a pharmaceutically acceptable salt thereof.

Embodiment II-36

The method of Embodiment II-35, wherein the third dose is administeredwithin about 8 to about 60 hours after administration of the seconddose.

Embodiment II-37

The method of Embodiment II-35 or II-36, further comprisingadministration of one to five additional doses of about 0.00003 mg toabout 0.030 mg of2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or acorresponding amount of a pharmaceutically acceptable salt thereof.

Embodiment II-38

The method of Embodiment II-37, wherein the administration of the one tofive additional doses is within about 8 to about 60 hours after theprior additional dose is administered.

Embodiment II-39

The method of any one of the preceding Embodiments, wherein the methodfurther comprises administering one or more doses of a progestogen.

Embodiment II-40

The method of any one of Embodiments II-1 to II-38, wherein the methoddoes not comprise administering one or more doses of a progestogen.

Embodiment II-41

The method of any one of the preceding Embodiments, wherein the methodfurther comprises oocyte retrieval.

Embodiment II-42

The method of Embodiment II-41, wherein the woman's pituitary isdesensitized to GnRH prior to administration of the initial dose.

Embodiment II-43

The method of any one of the preceding Embodiments, wherein the methodfurther comprises implantation of an embryo.

Embodiment II-44

The method of Embodiment II-43, wherein the implantation occurs withinabout 2 to about 10 days after administration of the initial dose.

Embodiment II-45

The method of Embodiment II-43 or II-44, wherein the implantation occurswithin about 1 to about 7 days after oocyte retrieval.

Embodiment II-46

The method of any one of Embodiments II-43 to II-45, wherein the embryohas not been frozen.

Embodiment II-47

The method of Embodiment II-46, wherein the embryo is implanted withinthe same menstrual cycle as oocyte retrieval.

Embodiment II-48

The method of any one of Embodiments II-1 to II-23, II-25 to II-26, orII-28 to II-30, wherein the method induces ovulation.

Embodiment II-49

The method of Embodiment II-48, wherein the woman conceives viaintercourse or intrauterine insemination after administration of atleast the initial dose.

Embodiment II-50

The method of any one of the preceding Embodiments, wherein afteradministration of at least the initial dose, the woman conceives and/orgives birth.

Embodiment II-51

The method of any one Embodiments II-1 to II-4 or II-6 to II-50, whereinone or more of the initial dose, second dose, third dose, or one to fiveadditional doses promotes luteal phase support.

Embodiment II-52

The method of any one of the preceding Embodiments, wherein one or moreof the initial dose, second dose, third dose, or one to five additionaldoses are administered via injection.

Embodiment II-53

The method of Embodiment II-52, wherein the injection is anintramuscular or subcutaneous injection.

Embodiment II-54

The method of any one of the preceding Embodiments, wherein any one ormore of the initial dose, second dose, third dose, or one to fiveadditional doses is from about 0.0003 mg to about 0.03 mg.

Embodiment II-55

The method of any one of the preceding Embodiments, wherein the woman isundergoing COS.

Embodiment II-56

The method of any one of the preceding Embodiments, wherein the ARTtherapy is selected from the group consisting of oocyte donation, oocytebanking, intracytoplasmic sperm injection (ICSI), IVF, embryo transfer(ET) process, ovulation induction, and intrauterine insemination.

Embodiment II-57

The method of any one of the preceding Embodiments, wherein the womanhas one or more of PCOS, serum AMH greater than 15 pmol/L, total AFCgreater than 23 via ultrasound, serum estradiol E2 greater than 3000pg/mL, or has experienced one or more previous episodes of OHSS.

Embodiment II-58

The method of any one of the preceding Embodiments, wherein the woman isany one or more of anovulatory, or of advanced maternal age, or isexperiencing secondary ovarian failure, oligomenorrhea, amenorrhea,endometriosis, or polyscystic ovarian syndrome (PCOS).

Embodiment II-59

A method of inducing final follicular maturation and early luteinizationin a woman in need thereof, wherein said woman is undergoing ART, hasundergone pituitary desensitization and has been pretreated withfollicle stimulating hormones as part of ART, said method comprisingadministering to the woman an initial dose of about 0.00003 mg to about0.030 mg of2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or acorresponding amount of a pharmaceutically acceptable salt thereof, andwherein after the initial dose is administered, the woman's endogenousLH level in blood is elevated compared to the woman's endogenous LHlevel in blood prior to administration of the initial dose.

Embodiment II-60

A method of inducing ovulation in a woman in need thereof, wherein saidwoman is anovulatory infertile and wherein said infertility is not dueto primary ovarian failure, said method comprising administering to thewoman an initial dose of about 0.00003 mg to about 0.030 mg of2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or acorresponding amount of a pharmaceutically acceptable salt thereof, andwherein after the initial dose is administered, the woman's endogenousLH level in blood is elevated compared to the woman's endogenous LHlevel in blood prior to administration of the initial dose.

Embodiment II-61

The method of Embodiment II-59 or II-60, wherein the woman is at riskfor OHSS.

Embodiment II-62

The method of any one of Embodiments II-59 to II-61, wherein at least 36hours after the initial dose is administered, the woman's endogenous LHlevel in blood is elevated compared to the woman's endogenous LH levelin blood prior to administration of the initial dose.

Embodiment II-63

The method of any one of Embodiments II-59 to II-62, wherein the maximumendogenous LH level in blood occurs at least about 12 hours afteradministration of the initial dose.

Embodiment II-64

The method of Embodiment II-63, wherein the maximum endogenous LH levelin blood occurs between about 12 hours and about 48 hours afteradministration of the initial dose.

Embodiment II-65

The method of any one of Embodiments II-59 to II-64, wherein the woman'sendogenous LH level in blood is elevated between about 12 hours to about96 hours after administration of the initial dose compared to thewoman's endogenous LH level in blood prior to administration of theinitial dose.

Embodiment II-66

The method of any one of Embodiments II-59 to II-65, wherein the woman'sendogenous LH level in blood is elevated for at least 36 hours afteradministration of the initial dose compared to the woman's endogenous LHlevel in blood prior to administration of the initial dose.

Embodiment II-67

The method of Embodiment II-66, wherein the endogenous LH level in bloodis elevated for about 36 hours to about 16 days.

Embodiment II-68

The method of Embodiment II-66, wherein the endogenous LH level in bloodis elevated for about 36 hours to about 12 days.

Embodiment II-69

The method of any one of the preceding Embodiments, wherein the womanexperiences anovulatory infertility not due to primary ovarian failure.

Embodiment II-70

The method of any one of the preceding Embodiments, said methodcomprising administering to the woman an initial dose of about 0.001 mgto about 0.003 mg of2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or acorresponding amount of a pharmaceutically acceptable salt thereof.

Embodiment II-71

The method of any one of Embodiments II-1 to II-69, said methodcomprising administering to the woman an initial dose of about 0.001 mgto about 0.030 mg of2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or acorresponding amount of a pharmaceutically acceptable salt thereof.

Embodiment II-72

The method of any one of Embodiments II-1 to II-69, said methodcomprising administering to the woman an initial dose of about 0.0003 mgto about 0.003 mg of2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or acorresponding amount of a pharmaceutically acceptable salt thereof.

Embodiment II-73

2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or apharmaceutically acceptable salt thereof, for use in a method ofelevating endogenous LH level in a woman who is undergoing ART and whois at risk for OHSS, the method comprising: administering to the womanan initial dose of about 0.00003 mg to about 0.030 mg of2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or acorresponding amount of the pharmaceutically acceptable salt thereof.

Embodiment II-74

The2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or apharmaceutically acceptable salt thereof for use according to EmbodimentII-73, wherein after the initial dose is administered, the woman'sendogenous LH level in blood is elevated compared to the woman'sendogenous LH level in blood prior to administration of the initialdose.

Embodiment II-75

2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or apharmaceutically acceptable salt thereof, for use in a method ofincreasing endogenous LH level in a woman undergoing ART, the methodcomprising:

administering to the woman an initial dose of about 0.00003 mg to about0.030 mg of2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or acorresponding amount of the pharmaceutically acceptable salt thereof.

Embodiment II-76

The2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamideor a pharmaceutically acceptable salt thereof for use according toEmbodiment II-75, wherein at least 36 hours after the initial dose isadministered, the woman's endogenous LH level in blood is elevatedcompared to the woman's endogenous LH level in blood prior toadministration of the initial dose.

Embodiment II-77

The2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or apharmaceutically acceptable salt thereof for use according to EmbodimentII-75, wherein the maximum endogenous LH level in blood occurs at leastabout 12 hours after administration of the initial dose.

Embodiment II-78

The2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or apharmaceutically acceptable salt thereof for use according to EmbodimentII-75, wherein the woman has received a trigger dose of an oocytematuration agent as part of an ART regimen prior to administration ofthe initial dose of2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or thepharmaceutically acceptable salt thereof.

Embodiment II-79

The2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamideor a pharmaceutically acceptable salt thereof for use according to anyone of the preceding Embodiments, wherein the initial dose isadministered when at least three ovarian follicles of at least 14 mm arevisible via ultrasound.

Embodiment II-80

The2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamideor a pharmaceutically acceptable salt thereof for use according to anyone of the preceding Embodiments, wherein the initial dose isadministered when at least three ovarian follicles of at least 18 mm arevisible via ultrasound.

Embodiment II-81

The2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamideor a pharmaceutically acceptable salt thereof for use according to anyone of the preceding Embodiments, wherein the initial dose isadministered when serum estradiol concentration is at least 0.49 nmol/L.

Embodiment II-82

The2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or apharmaceutically acceptable salt thereof for use according to any one ofthe preceding Embodiments, wherein the method further comprisesadministration of FSH about 5 days to about 12 days prior toadministration of the initial dose.

Embodiment II-83

The2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or apharmaceutically acceptable salt thereof for use according to any one ofthe preceding Embodiments, wherein the method further comprisesadministration of a GnRH antagonist about 2 days to about 10 days priorto administration of the initial dose.

Embodiment II-84

The2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or apharmaceutically acceptable salt thereof for use according to EmbodimentII-83, wherein the GnRH antagonist is selected from the group consistingof relugolix, elagolix, cetrorelix, ganirelix, abarelix, nal-blu,antide, azaline B, degarelix, D63153 (ozarelix), OBE2109, and teverelix.

Embodiment II-85

The2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or apharmaceutically acceptable salt thereof for use according to any one ofEmbodiments II-73 to II-84, wherein the method further comprisesadministration of a GnRH agonist from about 14 to about 28 days prior toadministration of the initial dose.

Embodiment II-86

The2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or apharmaceutically acceptable salt thereof for use according to EmbodimentII-85, wherein the GnRH agonist is selected from the group consisting ofleuprorelin acetate, gonadorelin, buserelin, triptorelin, goserelin,nafarelin, histrelin, deslorelin, meterelin, and lecirelin.

Embodiment II-87

The2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamideor a pharmaceutically acceptable salt thereof for use according to anyone of the preceding Embodiments, wherein the initial dose isadministered prior to oocyte retrieval.

Embodiment II-88

The2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamideor a pharmaceutically acceptable salt thereof for use according to anyone of Embodiments II-73 to II-87, wherein the initial dose isadministered after oocyte retrieval.

Embodiment II-89

The2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamideor a pharmaceutically acceptable salt thereof for use according to anyone of Embodiments II-73 to II-87, wherein the initial dose isadministered prior to ovulation.

Embodiment II-90

The2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamideor a pharmaceutically acceptable salt thereof for use according to anyone of Embodiments II-73 to II-87, wherein the initial dose isadministered after ovulation.

Embodiment II-91

The2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamideor a pharmaceutically acceptable salt thereof for use according to anyone of the preceding Embodiments, wherein the initial dose isadministered after administration of a GnRH agonist as an oocytematuration agent.

Embodiment II-92

The2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or apharmaceutically acceptable salt thereof for use according to EmbodimentII-91, wherein the GnRH agonist is selected from the group consisting ofleuprorelin acetate, gonadorelin, buserelin, triptorelin, goserelin,nafarelin, histrelin, deslorelin, meterelin, and lecirelin.

Embodiment II-93

The2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamideor a pharmaceutically acceptable salt thereof for use according to anyone of the preceding Embodiments, wherein the method further comprisesadministering a second dose of about 0.00003 mg to about 0.030 mg of2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide,or a corresponding amount of a pharmaceutically acceptable salt thereof.

Embodiment II-94

The2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or apharmaceutically acceptable salt thereof for use according to EmbodimentII-93, wherein the second dose is administered within about 8 to about60 hours after administration of the initial dose.

Embodiment II-95

The2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamideor a pharmaceutically acceptable salt thereof for use according toEmbodiment II-93 or II-94, wherein the method further comprisesadministering a third dose of about 0.00003 mg to about 0.030 mg of2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide,or a corresponding amount of a pharmaceutically acceptable salt thereof.

Embodiment II-96

The2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or apharmaceutically acceptable salt thereof for use according to EmbodimentII-95, wherein the third dose is administered within about 8 to about 60hours after administration of the second dose.

Embodiment II-97

The2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or apharmaceutically acceptable salt thereof for use according to EmbodimentII-95 or II-96, wherein the method further comprises administration ofone to five additional doses of about 0.00003 mg to about 0.030 mg of2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide,or a corresponding amount of a pharmaceutically acceptable salt thereof.

Embodiment II-98

The2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamideor a pharmaceutically acceptable salt thereof for use according toEmbodiment II-97, wherein the administration of the one to fiveadditional doses is within about 8 to about 60 hours after the prioradditional dose is administered.

Embodiment II-99

The2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamideor a pharmaceutically acceptable salt thereof for use according to anyone of the preceding Embodiments, wherein the method further comprisesadministering one or more doses of a progestogen.

Embodiment II-100

The2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamideor a pharmaceutically acceptable salt thereof for use according to anyone of Embodiments II-73 to II-98, wherein the method does not compriseadministering one or more doses of a progestogen.

Embodiment II-101

The2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamideor a pharmaceutically acceptable salt thereof for use according to anyone of the preceding Embodiments, wherein one or more of the initialdose, second dose, third dose, or one to five additional doses areadministered via injection.

Embodiment II-102

The2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or apharmaceutically acceptable salt thereof for use according to EmbodimentII-101, wherein the injection is an intramuscular or subcutaneousinjection.

Embodiment II-103

The2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamideor a pharmaceutically acceptable salt thereof for use according to anyone of the preceding Embodiments, wherein any one or more of the initialdose, second dose, third dose, or one to five additional doses is fromabout 0.0003 mg to about 0.03 mg.

Embodiment II-104

The2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamideor a pharmaceutically acceptable salt thereof for use according to anyone of the preceding Embodiments, wherein the woman is undergoing COS.

Embodiment II-105

The2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or apharmaceutically acceptable salt thereof for use according to any one ofthe preceding Embodiments, wherein the ART therapy is selected from thegroup consisting of oocyte donation, oocyte banking, ICSI, IVF, an ETprocess, ovulation induction, and intrauterine insemination.

Embodiment II-106

The2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or apharmaceutically acceptable salt thereof for use according to any one ofthe preceding Embodiments, wherein the woman has one or more of PCOS,serum AMH greater than 15 pmol/L, total AFC greater than 23 viaultrasound, serum estradiol E2 greater than 3000 pg/mL, or hasexperienced one or more previous episodes of OHSS.

Embodiment II-107

The2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or apharmaceutically acceptable salt thereof for use according to any one ofthe preceding Embodiments, wherein the woman is any one or more ofanovulatory, or of advanced maternal age, or is experiencing secondaryovarian failure, oligomenorrhea, amenorrhea, endometriosis, orpolyscystic ovarian syndrome (PCOS).

Embodiment II-108

2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or apharmaceutically acceptable salt thereof for use in a method of inducingfinal follicular maturation and early luteinization in a woman who isundergoing ART, has undergone pituitary desensitization and has beenpretreated with follicle stimulating hormones as part of ART, saidmethod comprising administering to the woman an initial dose of about0.00003 mg to about 0.030 mg of2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or acorresponding amount of the pharmaceutically acceptable salt thereof.

Embodiment II-109

The2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or apharmaceutically acceptable salt thereof for use according to EmbodimentII-108, wherein after the initial dose is administered, the woman'sendogenous LH level in blood is elevated compared to the woman'sendogenous LH level in blood prior to administration of the initialdose.

Embodiment II-110

2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or apharmaceutically acceptable salt thereof for use in a method of inducingovulation in a woman who is anovulatory infertile, wherein saidinfertility is not due to primary ovarian failure, said methodcomprising administering to the woman an initial dose of 0.00003 mg toabout 0.030 mg of2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or acorresponding amount of the pharmaceutically acceptable salt thereof.

Embodiment II-111

The2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or apharmaceutically acceptable salt thereof for use according to EmbodimentII-110, wherein after the initial dose is administered, the woman'sendogenous LH level in blood is elevated compared to the woman'sendogenous LH level in blood prior to administration of the initialdose.

Embodiment II-112

The2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamideor a pharmaceutically acceptable salt thereof for use according to anyone of Embodiments II-108 to II-111, wherein the woman is at risk forOHSS.

Embodiment II-113

The2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or apharmaceutically acceptable salt thereof for use according to any one ofthe preceding Embodiments, wherein the initial dose is 0.001 mg to about0.003 mg2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or acorresponding amount of a pharmaceutically acceptable salt thereof.

Embodiment II-114

The2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamideor a pharmaceutically acceptable salt thereof for use according to anyone of Embodiments II-73 to II-112, wherein the initial dose is 0.001 mgto about 0.030 mg of2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or acorresponding amount of a pharmaceutically acceptable salt thereof.

Embodiment II-115

The2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or apharmaceutically acceptable salt thereof for use according to any one ofEmbodiments II-73 to II-112, wherein the initial dose is 0.0003 mg toabout 0.003 mg of2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or acorresponding amount of a pharmaceutically acceptable salt thereof.

Embodiment II-116

Use of2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide,or a pharmaceutically acceptable salt thereof, for the manufacture of amedicament for elevating endogenous LH level in a woman who isundergoing ART and who is at risk for OHSS.

Embodiment II-117

Use of2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide,or a pharmaceutically acceptable salt thereof, for the manufacture of amedicament for increasing endogenous LH level in a woman undergoing ART.

Embodiment II-118

Use of2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide,or a pharmaceutically acceptable salt thereof, for the manufacture of amedicament for inducing final follicular maturation and earlyluteinization in a woman who is undergoing ART, has undergone pituitarydesensitization and has been pretreated with follicle stimulatinghormones as part of ART.

Embodiment II-119

Use of2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or apharmaceutically acceptable salt thereof, for the manufacture of amedicament for inducing ovulation in a woman who is anovulatoryinfertile, wherein said infertility is not due to primary ovarianfailure.

What is claimed is:
 1. A method of increasing endogenous luteinizinghormone (LH) level in a woman in need thereof undergoing assistedreproductive technology, the method comprising: administering to thewoman an initial dose of about 0.0003 mg to 0.015 mg of2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or acorresponding amount of a pharmaceutically acceptable salt thereof,wherein the woman is undergoing assisted reproductive technology, andwherein the maximum endogenous LH level in blood occurs between about 12hours and about 48 hours after administration of the initial dose. 2.The method of claim 1, wherein the maximum endogenous LH level in bloodoccurs between about 18 hours and about 48 hours after administration ofthe initial dose.
 3. The method of claim 1, wherein oocyte maturationoccurs without the administration of exogenous human chorionicgonadotropin or exogenous LH.
 4. The method of claim 1, wherein theinitial dose is administered when at least three ovarian follicles of atleast 14 mm are visible via ultrasound.
 5. The method of claim 1,wherein the initial dose is administered when at least three ovarianfollicles of at least 18 mm are visible via ultrasound.
 6. The method ofclaim 1, wherein the initial dose is administered when serum estradiolconcentration is at least 0.49 nmol/L.
 7. The method of claim 1, whereinthe method comprises administration of a GnRH antagonist about 2 days toabout 10 days prior to administration of the initial dose.
 8. The methodof claim 7, wherein the GnRH antagonist is selected from the groupconsisting of relugolix, elagolix, cetrorelix, ganirelix, abarelix,nal-blu, antide, azaline B, degarelix, D63153 (ozarelix), OBE2109, andteverelix.
 9. The method of claim 1, wherein the initial dose isadministered prior to oocyte retrieval.
 10. The method of claim 1,wherein the method comprises administering a second dose of about 0.0003mg to 0.015 mg of2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or acorresponding amount of a pharmaceutically acceptable salt thereof. 11.The method of claim 1, wherein the woman has one or more of polycysticovarian syndrome, serum anti-Müllerian hormone greater than 15 pmol/L,total antral follicle count greater than 23 via ultrasound, serumestradiol E2 greater than 3000 pg/mL, or has experienced one or moreprevious episodes of ovarian hyperstimulation syndrome.
 12. The methodof claim 1, wherein the woman is any one or more of anovulatory, or ofadvanced maternal age, or is experiencing secondary ovarian failure,oligomenorrhea, amenorrhea, endometriosis, or polycystic ovariansyndrome.
 13. The method of claim 1, wherein the woman is at risk forovarian hyperstimulation syndrome.
 14. The method of claim 1, whereinthe woman does not experience one or more symptoms of ovarianhyperstimulation syndrome after administration of the initial dose. 15.The method of claim 1, wherein the woman has ovarian hyperstimulationsyndrome and wherein after administration of the initial dose, the womandoes not experience a worsening of one or more symptoms of ovarianhyperstimulation syndrome.
 16. The method of claim 1, wherein thewoman's endogenous LH level in blood is elevated for at least 48 hoursafter administration of the initial dose of2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or acorresponding amount of a pharmaceutically acceptable salt thereof,compared to the woman's endogenous LH level in blood prior toadministration of the initial dose.
 17. The method of claim 1, whereinthe woman's endogenous LH level in blood is elevated between about 14hours to about 84 hours after administration of the initial dose of2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or acorresponding amount of a pharmaceutically acceptable salt thereof,compared to the woman's endogenous LH level in blood prior toadministration of the initial dose.